以DRG为导向的血液透析患者疾病编码质量控制实践

DRG-oriented quality control of disease coding for hemodialysis patients

目的以疾病诊断相关分组为导向,对血液透析患者疾病和手术操作的编码使用情况进行分析,以提高编码工作人员的编码准确率。方法收集某医院2023年1—6月干预前的血液透析科住院病案607份(排除肾损伤患者)作为对照组。并以DRG为导向查找存在的问题,分析原因,制定针对性整改措施。选取2023年7—12月实行干预后的血液透析科住院病案607份(排除肾损伤患者)作为观察组,比较两组编码质量。结果观察组的疾病诊断编码错误率(占6.64%)较对照组的低(占26.21%),观察组的手术编码错误率(占3.49%)较对照组的(占12.15%)下降明显,差异均有统计学意义(P<0.05),同时对DRG入组情况进行分析,住院病案的诊断和操作的准确性对DRG存在影响。结论编码员对血液透析并发症和相关手术操作编码掌握不准确,缺乏通读病历和运用工具书的习惯,需要通过不断加强对编码理论和实践的学习,并充分运用首页质控监测系统,以提高编码水平,提高DRG正确入组率。

Objective To analyze the disease and surgical procedure coding for hemodialysis patients based on Diagnosis-Related Groups(DRGs)to improve coding accuracy.Methods A total of 607 inpatient medical records from the hemodialysis department of a hospital from January to June 2023 were included as the control group,with the cases with kidney injury excluded.DRG-oriented issues were identified and causes were analyzed.Targeted measures were proposed and implemented for intervening with the disease and surgical procedure coding in the department.Another set of 607 inpatient medical records from the hemodialysis department from July to December 2023 served as the observation group,with cases of kidney injury excluded as well.The coding quality was compared between the two groups.Results The observation group showed significantly lower error rates of disease diagnosis coding and surgical procedure coding(6.64%vs.26.21%,P<0.05);(3.49%vs.12.15%,P<0.05,respectively),compared to the control group.Additionally,analysis of DRG grouping showed that coding accuracy for diagnoses and procedures directly impacted DRG assignment.Conclusion Coders don’t master coding rules thoroughly for hemodialysis complications and related surgical procedures.They lack the habit of comprehensively reading medical records and using reference books.It is crucial for them to enhance ongoing education in coding theory and practice.Additionally,they are also suggested to fully utilize the quality control monitoring system on the first pages of medical records to improve coding ability and increase the accuracy of DRG grouping.