基于DRGs未入组病案编码质量分析  

Analysis on the Coding Quality of Unincorporated Medical Records based on DRGs

作　　者：杨洋[1,2] 刘慧悦[1] 金敏[1] 张静[1] 陈金彪[1] 赵利[1] Yang Yang;Liu Huiyue;Jin Min;Zhang Jing;Chen Jinbiao;Zhao Li(Medical Record Management and Information Statistics Center,Xiangya hospital central-south university&Hospital Administration Institute,CSU,Changsha 410008,Hunan Province,China;不详)

机构地区：[1]中南大学湘雅医院病案管理与信息统计中心,湖南省长沙市410008 [2]中南大学医院管理研究所,湖南省长沙市410008

出　　处：《中国病案》2022年第9期20-22,共3页Chinese Medical Record

基　　金：中南大学湘雅医院管理研究基金项目(2019GL15)。

摘　　要：目的分析湖南省某三甲医院DRGs分组系统中未入组的病案,查找病案编码问题,提出相应的改进措施,提高DRGs入组率和编码准确率。方法将2020年7月1日-2021年6月30日出院的154258份住院病案首页数据导入CN-DRG系统进行分组,组织专家回顾性分析未入组病案中存在的编码问题,并对其进行责任划分。结果未入组病案1060份,其中155份(14.6%)因编码问题无法入组,原因包括编码员编码错误89份(57.42%)、临床医师填写缺陷58份(37.42%)和信息系统问题8份(5.16%)。修正问题后154份病案进入20个MDC,例数最多的为MDCD头颈、耳、鼻、口、咽疾病及功能障碍。结论运用DRGs分组系统可核查病案编码质量,应提高编码员编码能力,加强临床医师培训,优化信息系统,建立住院病案首页填写和编码质控体系,切实提升住院病案首页质量。Objectives This study aims to analyze the unincorporated medical records of DRGs grouping system of a Three A and Tertiary hospital in Hunan Province,explore the existing coding problems,and proposing corresponding measures to improve the enrollment rate of DRGs and coding accuracy.Methods Data from 154258 medical record front pages of discharged patients from July 1,2020 to July 30,2021 were imported and grouped by CN-DRG system.Experts were organized to retrospectively analyze the coding problems in unincorporated medical records and divide the responsibilities for the problems.Results A total of 1060 medical records were not enrolled,of which 155(14.6%)could not be enrolled due to coding defects.The reasons included coding errors of 89 cases(57.42%),clinicians’filling defects of 58 cases(37.42%)and information system problems of 8 cases(5.16%).After correcting the problems,152 medical records were enrolled into 20 MDCs.The largest number of cases were MDCD-diseases and disorders of the ear,nose,mouth and throat.Conclusions The DRGs grouping system can be used to check the quality of coding.To effectively improve the quality of the medical record front pages,hospitals should promote the coding ability of the coders,strengthen the training of clinicians,optimize the information system,and establish a quality control system for medical record filling and coding.

关 键 词：DRGS 未入组病案 编码质量 

分 类 号：R197.323[医药卫生—卫生事业管理]