摘要
目的 通过分析某三甲综合医院QY病案产生的原因,提高病案首页填报质量和DRG入组准确率。方法 调取某院院内DRG分组平台中2019年7月1日-2020年6月30日住院病案首页DRG预分组为QY的病案161例,组织病案质控医师和高年资编码员,通过查阅病案资料得到编码不入组原因,采用Excel2010对数据进行统计分析并绘制帕累托图。结果 产生QY病案原因类型:主要因素为DRG分组规则缺陷及主要诊断错误,构成比分别为32.3%和26.09%;一般因素为同次住院治疗多种疾病,构成比为23.6%;次要因素为主要手术操作错误及诊断与手术操作同时错误,构成比分别为13.04%和4.97%。结论 QY病案产生的原因是多方面的,医院要加强对医师和编码员的培训工作,建立病案首页数据质控长效机制,从而提高病案首页数据质量、减少或避免QY病案的发生、进一步提高DRG入组准确率。
Objectives By analyzing the causes of QY medical records in a Three A and Tertiary General Hospital,to improve the quality of the front page of medical records and the accuracy of DRG inclusion.Methods A total of 161 cases of inpatient medical records that were pre-grouped as QY by DRG on the front page of the hospital DRG grouping platform from July 1 st,2019 to June 30 th,2020 were collected.The quality control physicians and senior coders of medical records were organized to obtain the reason why the codes were not included in the group by consulting the medical record data.Excel2010 was used for statistical analysis of the data and pareto diagram was drawn.Results Causes of QY included these types:the main factors were the defect of DRG grouping rule and the main diagnostic error,the component ratio was 32.3% and 26.09%,respectively.The common factors were multiple diseases treated at the same time,with a constituent ratio of 23.6%.The secondary factors were major surgical errors and simultaneous errors of diagnosis and operation,with constituent ratios of 13.04% and 4.97%,respectively.Conclusions The causes of QY medical records were various.The hospital should strengthen the training of doctors and coders and establish a long-term mechanism for quality control of the front page data of medical records,so as to improve the quality of the first page data of medical records,reduce or avoid the occurrence of QY medical records and further improve the accuracy of DRG inclusion.
作者
孟洁
刘辰雨
张梦蝶
Meng Jie;Liu Chenyu;Zhang Mengdie(Department of Medical Records,Beijing Friendship Hospital Affiliated to Capital Medical University,Beijing 100050,China;不详)
出处
《中国病案》
2022年第3期9-12,共4页
Chinese Medical Record
