应用DRGs指标分析重症医学科出院病案首页质量  

Quality Control of the Front Sheet of ICU Inpatients By Using DRGs Indexes

作　　者：梁雪平[1] Liang Xueping(Jiangmen Central Hospital,Jiangmen 529030,Guangdong Province,China)

机构地区：[1]广东省江门市中心医院,广东省江门市529030

出　　处：《中国病案》2022年第4期9-12,共4页Chinese Medical Record

摘　　要：目的 通过分析某综合医院重症医学科诊断和手术操作编码及其DRGs入组的情况,为提升住院病案首页质量提出改进措施。方法 收集2019年1月1日-2019年12月31日出院的重症医学科病案343份,剔除住院天数大于60天的病例7例,余下336例。应用广东省医疗机构病案统计管理系统与广东省DRGs住院医疗服务综合评价系统2019年的平台数据,未入DRG组病例、低于医院平均CMI值的病例,应用Microsoft Office Excel 2007工作表对上述两个平台的数据整合,列出质控项目的具体错误原因分类汇总,计算缺陷占比。结果 重症医学科住院病案首页发现错误病例21例,占重症医学科出院病案6.12%,21例病例修改前总权重15.21,修改后总权重84.6,是原来的5.56倍,代表ICU实际住院服务产出更大。其中单纯主要诊断错误7例,单纯手术操作缺漏14例(其中13例均为漏呼吸机治疗操作),诊断错误兼操作缺漏1例。1例为编码错误造成,其余20例为医师选择主要诊断和缺漏手术操作造成。修正后3例歧义病案均入组,16例CMI高于全院均值,新增5个DRG组,代表ICU能提供的实际诊疗服务范围更大。21例中有13例为转科和转院接收病例,占比61.90%。结论 应用DRGs指标质控能提升住院病案首页数据质量,提高医师填写住院病案首页的重视度和编码员的工作责任心,增强医院信息智能化,持续改进医疗质量安全。Objective To analyze coding of the diagnosis and operation and its DRGs from the discharge patients of ICU of one comprehensive hospital,explore measurement to improve the data quality of the front sheet.Methods A total of 343 critical medical records discharged from January 1,2019 to December 31,2019 were collected.7cases with hospitalization days more than 60 days were excluded,and the remaining 336 cases were excluded.Using the platform data of Guangdong Medical institutions Medical record Statistics Management system and Guangdong DRGs hospitalization Medical Service Comprehensive Evaluation system in 2019,for those cases not included in the DRG group and cases lower than the average CMI value of the hospital,the data of the above two platforms are integrated with Microsoft Office Excel 2007 worksheet,the specific error causes of quality control items are classified and summarized,and the proportion of defects is calculated.Results 21 erroneous cases were found on the home page of the hospitalization records of the intensive care department,accounting for 6.12% of the discharged medical records of the critical medicine department.The total weight of 21 cases before revision was 15.21,and the total weight after revision was 84.6,which was 5.56 times that of the original,which represented that the actual output of hospitalization services of ICU was greater.Among them,7 cases were mainly misdiagnosed,14 cases were missed in simple operation(13 cases were treated by leaky ventilator),and 1 case was misdiagnosed and missed in operation.One case was caused by coding error,and the other 20 cases were caused by doctors’ choice of main diagnosis and omission operation.After correction,3 ambiguous medical records were included in the group,and the CMI of 16 cases was higher than the average value of the whole hospital,and 5 new DRG groups were added,which indicated that ICU could provide a wider range of diagnosis and treatment services.Of the 21 cases,13 cases were transferred to the department and transferred to h

关 键 词：重症医学科 病案首页 ICD编码 DRGs分组 

分 类 号：R197.323[医药卫生—卫生事业管理]