疾病诊断相关分组中高倍率病例的病案首页数据缺陷情况分析

Analysis of data defects on the first page of medical records of high magnification cases in disease diagnosis related groups

目的 通过对疾病诊断相关组(DRGs)高倍率病历首页进行分析发现存在的缺陷,并提出相应改进措施。方法对某三甲医院2022年6月至2023年5月医院医保监管系统反馈的1 089份高倍率病例进行回顾性分析,分类统计病案首页数据缺陷情况。采用相关性分析,用回归分析方法对变量之间因果关系进行验证。结果 1 089例DRG高倍率病例中,共有131份存在缺陷问题,其中外科组占比最高,临床医生错填导致的高倍率病例占比96.18%,医生错误类型为:主要诊断选择错误、主要手术选择错误以及手术操作漏填或漏编,错误占比46.56%、20.61%、29.01%。由编码员错误导致的首页缺陷类型为:主要诊断选择错误、主要手术选择错误、分别占比2.29%、1.53%。主要诊断选择错误、主要手术选择错误以及手术操作漏填或漏编与误入高倍率病例组的关系中存在相关关系(P<0.05)。结论 通过对DRG中高倍率病例的病案首页数据缺陷情况分析,发现主要诊断选择错误、主要手术选择错误是缺陷的主要类型,其和误入高倍率病例组有相关性。医疗机构应通过加强DRG相关人员培训以更好地适应DRG收费改革。

Objective To analyze the defective problems in the first page of medical records of high magnification cases in disease diagnosis related groups(DRGs) and propose improvement measures.Methods A total of 1 089 high rate cases were fed back by the municipal medical insurance supervision system from June 2022 to May 2023 in a third class hospital were analyzed retrospectively.The defects on the first page of medical records were classified and counted.Correlation analysis was carried out,and regression analysis was used to verify the causal relationship between variables.Results A total of 131of 1 089 high rate cases were found to have defect problems,with the surgical group had the highest proportion.The main reason for these mistakes was clinicians' incorrect filling,accounting for 96.18%.The types of errors on the first page due to clinicians' mistakes were main diagnosis selection errors,main surgery selection errors and surgical operations missed or omitted,accounting for 46.56%,20.61% and 29.01% respectively.The types of errors on the first page due to coders' mistakes were main diagnosis selection errors and main surgery selection errors,accounting for 2.29% and 1.53% respectively.The relationship between main diagnosis selection errors,main surgery selection errors,and surgical operations missed or omitted and high incidence of misdiagnosis cases showed a correlation(P<0.05).Conclusion By analyzing the data defects on the first page of medical records of high magnification cases in disease diagnosis related groups,we found that the main types of defects are incorrect selection of main diagnosis and incorrect selection of main surgery.These defects are related to the high incidence of misdiagnosis cases.Therefore,medical institutions should enhance the training of DRG related personnel to better adapt to the DRG payment reform.