摘要
目的分析呼吸机操作名称填报错误对DRGs入组的影响,提高该操作名称编码的准确性,为三级公立医院绩效考核和医保DRGs付费提供有效的数据支撑。方法利用某医院HIS收费系统检索2021年7月1日至2021年12月31日使用呼吸机的患者出院病案,对病案首页的呼吸机操作相关填报内容进行质控,核查临床实际书写情况与病案编码员编码情况,汇总分析后将错误病例进行修正,再次模拟DRGs入组并进行分析对比。结果使用呼吸机的患者出院病案共936份,检查出问题病案17份。其中,遗漏呼吸机相关操作名称8份,占47.06%,缺陷率0.85%;呼吸机使用时间书写错误5份,占29.41%,缺陷率0.53%;呼吸机类型书写/编码错误2份,占11.76%,缺陷率0.21%;使用医保大类编码2份,占11.76%,缺陷率0.21%。经修正后模拟DRGs入组,填报错误导致DRGs入组差异大,权重降低,全院亏损892378.87元。结论呼吸机操作填报错误,主要是由于医师遗漏操作名称或时间填写错误、编码员编码错误造成。应建立病案首页信息化监测系统,加强病案首页规范化填写培训,成立三级质量控制管理小组,提高DRGs入组准确性。
Objective To analyze the influence of incorrect filling of ventilator operation name on DRGs enrollment,improve the accuracy of operation name coding,and provide effective data support for the performance appraisal of tertiary public hospitals and medical insurance DRGs payment.Methods Based on HIS charging system,936 medical records of patients discharged from a hospital using ventilators from July 1,2021 to December 31,2021 were retrieved.The contents related to ventilator operation in the first page of medical records were quality-controlled,the actual clinical writing and the coding of medical records were checked,and the wrong cases were corrected after summary and analysis.DRGs was simulated again and analyzed and compared.Results There were 936 medical records of patients discharged from the hospital using ventilators,and there were 17 with problems,including 8 with missing ventilator-related operation names,accounting for 47.06%with the defect rate 0.85%,5 with writing errors in ventilator use time,accounting for 29.41%with the defect rate 0.53%,2 with errors in writing/coding of ventilator types,accounting for 11.76%with the defect rate 0.21%,and 2 with coding of medical insurance,accounted for 11.76%with the defect rate 0.21%.After correction and with the simulation of DRGs,the filling error led to a big difference in the DRGs enrollment,the weight was reduced,and the hospital lost 892378.87 yuan.Conclusion The errors in ventilator operation were mainly caused by the omission of operation name or the error of operation time by doctors and the coding errors of coders.It is necessary to establish an information monitoring system for the first page of medical records,strengthen the training of standardized filling in the first page of medical records,set up a three-level quality control management team,and improve the accuracy of DRGs inclusion.
作者
顾晓敏
赵青
Gu Xiaomin;Zhao Qing(Medical Records Management Center,Huzhou Central Hospital,Huzhou 313000,China;Department of Medical Records,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences,Beijing 100730,China)
出处
《中国医院统计》
2022年第5期367-372,共6页
Chinese Journal of Hospital Statistics
关键词
病案首页
DRGS
呼吸机
编码
medical record home page
DRGs
ventilator
coding
