基于DRG某院高倍率病例的病案首页填写问题及对策研究  

Research on the Problems and Countermeasures of Filling in the First Page of Medical Records of High Magnification Cases in a Hospital Based on DRG

作　　者：王丽 娄琳琳 刘颖 WANG Li;LOU Linlin;LIU Ying(Department of Medical Records Statistics,Affiliated Hospital of Xuzhou Medical University,Xuzhou Jiangsu 221000,China)

机构地区：[1]徐州医科大学附属医院病案统计科,江苏徐州221000

出　　处：《中国卫生标准管理》2023年第2期20-25,共6页China Health Standard Management

摘　　要：目的在疾病诊断相关组(diagnosis related groups,DRG)支付改革背景下,分析某三甲医院因病案首页诊断及手术操作填写问题进入高倍率组的病例,有效提高DRG入组的准确率。方法回顾性分析某三甲医院2022年1—6月市医保监管平台反馈的918份高倍率病例,统计归纳首页填写错误类型。结果分析174份病例误入高倍率病例组的原因主要是临床医生错填、编码员错编以及DRG分组器原因,分别占比64.94%、29.89%、5.17%;其中165份因临床医生错填或编码员错编的首页填写错误类型为:主要诊断选择错误、主要手术选择错误、其他诊断以及手术操作漏填或漏编,分别占比43.03%、27.27%、18.79%、10.91%。结论分析高倍率病例的诊断及手术操作错填或漏填的原因,通过加强DRG相关培训指导、信息化支持以及建立多部门协同质控机制来持续改进病案首页数据质量,促进医院发展更好地适应DRG支付改革。Objective Under the background of diagnosis related groups payment reform,to analyze the cases that a tertiary hospital entered the high rate group due to the problems of diagnosis on the first page of medical records and filling in the surgical procedures,so as to effectively improve the accuracy of DRG enrollment.Methods A total of 918 high rate cases fed back by the municipal medical insurance supervision platform from January to June 2022 in a third class hospital were analyzed retrospectively,and the types of errors filled in the front page were summarized.Results The main reasons for 174cases entering the high rate group by mistake were clinicians’wrong filling,coders’wrong coding and DRG grouping devices,accounting for 64.94%,29.89%and 5.17%respectively;In 165 cases,the types of errors on the first page due to clinicians’mistakes or coders’mistakes were main diagnosis selection errors,main surgery selection errors,other diagnoses and surgical operations missed or omitted,accounting for 43.03%,27.27%,18.79%and 10.91%respectively.Conclusion To analyze the causes of misdiagnosis or omission in the diagnosis of high rate cases and surgical operations,and to continuously improve the quality of the first page data of medical records by strengthening DRG related training guidance,information support and establishing a multi department collaborative quality control mechanism,so as to promote the development of hospitals to better adapt to the DRG payment reform.

关 键 词：DRG 病案首页 高倍率 原因分析 数据质量 改进措施 

分 类 号：R197[医药卫生—卫生事业管理]