摘要
目的分析DRGs付费下某院先天性心脏病病例的DRGs分组和病案首页编码情况,提高分组的准确率及编码质量。方法选取2018年1月1日-2019年8月31日某院DRGs月度预付初审分组结果阶段的先天性心脏病的124份病例,查看每份病案首页诊断和手术操作的填写、主要诊断和主要手术操作的选择、诊断和手术操作的编码与病程记录、出院记录、手术记录、病理报告及检查单等。结果 124例主要诊断为先天性心脏病的病例中有20例存在编码问题,其中主要手术编码错误7例,占比5.64%,主要手术未精细编码5例,占比4.03%,主要手术编码上传缺失4例,占比3.23%,主要诊断编码错误1例,占比0.80%,主要手术错填及编码错误1例,占比0.8%,主要手术选择及编码错误1例,占比0.8%,漏填其他手术操作编码1例,占比0.80%。结论编码员编码错误和未精细编码、临床医师病案首页填写错误、医院信息系统及上传接口未完善是影响某院病案首页编码质量及月度预付初审分组阶段DRGs分组准确率的主要原因。
Objective To analyze the DRGs grouping and home page coding of congenital heart disease cases in a hospital under DRGs payment,so as to improve the grouping accuracy and coding quality.Methods From January1st,2018 to August 31st,2019,124 cases of congenital heart disease in a hospital DRGs monthly pre-paid preliminary examination grouping result stage were reviewed to see the filling in of diagnosis and operation on the front page of each case,selection of main diagnosis and operation,coding and course record of diagnosis and operation,discharge record,operation record,pathology report and checklist,etc.Results Among the 124 cases diagnosed as congenital heart disease,20 cases had coding related problems,of which 7 cases were coding errors,accounting for 5.64%,5 cases were not precisely coded,accounting for 4.03%,There were 4 cases of main operation code upload missing,accounting for 3.23%,1 case of main diagnosis code error,accounting for 0.80%,1 case of main operation wrong filling and coding error,accounting for 0.8%,1 case of main operation selection and coding error,accounting for 0.8%,and 1 case of other operation code missing,accounting for 0.8%.Conclusions The coding error of the coder and the imprecise coding,the filling error of the front page of the medical record of the clinician,the imperfection of the hospital information system and the upload interface affected the quality of the front page coding of the medical record of the hospital and the accuracy of the DRGs grouping in the monthly pre-paid preliminary examination grouping stage.
作者
韦艳灵
肖晓兰
Wei Yanling;Xiao Xiaolan(Department of Medical Records,Liuzhou Maternity and Child Healthcare Hospital,Liuzhou 545000,Guangxi Zhuang Autonomous Region,China;不详)
出处
《中国病案》
2020年第5期4-6,共3页
Chinese Medical Record
关键词
DRGS
先天性心脏病
ICD
编码
病案首页
DRGs
Congenital heart disease
ICD
Coding
Front page of medical record
