CHS-DRG细分组方案(1.1版)歧义病案产生的影响因素分析  

Analysis of Influencing Factors of Ambiguous Cases in CHS-DRG Subdivision Scheme(Version 1.1)

作　　者：胡颜芳 朱小芳 陈燕敏 王梦丹 HU Yanfang;ZHU Xiaofang;CHEN Yanmin;WANG Mengdan(Department of Medical Record Statistics,Wuyishan Municipal Hospital,Wuyishan Fujian 354300,China)

机构地区：[1]武夷山市立医院病案统计室,福建武夷山354300

出　　处：《中国卫生标准管理》2023年第14期11-15,共5页China Health Standard Management

摘　　要：目的通过对南平市某二甲医院歧义病案产生的原因分析,提高疾病诊断相关分组(diagnosis related groups,DRGs)的正确入组率。方法回顾性调查2023年1—4月南平市某二甲医院7675份病案,依据国际疾病分类(international classification of diseases,ICD-10)和手术操作分类(international classification of diseases clinical modificationof9threvisionoperationsandprocedures,ICD-9-CM-3)的编码规则以及国家医疗保障疾病诊断相关分组(China healthcare security diagnosis related groups,CHS-DRG)细分组方案(1.1版),分析歧义病案产生的影响因素。结果7675份住院病案首页参与分组病案6923份,共有异常分组病案205份,其中空白病组病案3份;歧义病案202份,占分组病案的2.92%。产生歧义病案的主要因素有:主要诊断选择错误、主要手术选择有误、主要手术与主要诊断不在同一主要诊断大类(major diagnostic category,MDC)、同次住院多疾病共治等。结论针对歧义病案产生的主要原因应加强临床医师和编码员住院病案首页填报和DRG相关知识的培训,做好病案首页质量事前控制工作,提高病案正确入组率。Objective To improve the correct enrollment rate of diagnosis related groups(DRGs) by analyzing the causes of ambiguous cases in a second class hospital in Nanping City.Methods A retrospective investigation was conducted on 7 675medical records of a second class hospital in Nanping City from January to April 2023.According to the international classification of diseases(ICD-10),international classification of diseases clinical modification of 9th revision operations and procedures(ICD-9-CM-3),and the detailed grouping scheme of China healthcare security diagnosis related groups(CHS-DRG)(version 1.1) were used to analyze the influencing factors of ambiguous medical records.Results There were 6 923 grouped cases involved in the first page of 7 675 inpatient cases,and there were 205 abnormal grouped cases:including 3 cases of blank disease group,202ambiguous cases,accounting for 2.92% of the grouped cases.The main factors that cause ambiguous medical records are,incorrect selection of the main diagnosis,incorrect selection of the main surgery,the main surgery and the main diagnosis are not in the same major diagnostic category(MDC),and multiple diseases are treated in the same hospitalization.Conclusion To address the main causes of ambiguous cases,we should strengthen the training of clinicians and coders on inpatient case home filling and DRGrelated knowledge,and do a good job of prior control of case home quality to improve the rate of correct case entry.

关 键 词：细分组方案1.1版 疾病诊断相关分组 歧义病案 主要诊断选择 主要手术操作选择 影响因素 

分 类 号：R197[医药卫生—卫生事业管理]