DRG应用中歧义病案的产生及对策  

Generation and countermeasures of ambiguous medical records in DRG application

作　　者：樊书娟[1] 闫学丽 张萌[1] 邵渊[1] 张文[1] 左煌[1] FAN Shujuan;YAN Xueli;ZHANG Meng;SHAO Yuan;ZHANG Wen;ZUO Huang(The First Affiliated Hospital of Xi’an Jiaotong University,Xi’an 710061,China)

机构地区：[1]西安交通大学第一附属医院,陕西西安710061

出　　处：《现代医院》2025年第3期371-374,共4页Modern Hospitals

基　　金：国家自然科学基金(81501608)。

摘　　要：目的分析歧义病案产生的根本原因、影响因素,并提出针对性的干预对策。方法回顾性收集西安市某大型三甲医院耳鼻喉头颈外科2023年1-12月间结算出院病案,通过DRG信息平台筛选病案分组和歧义病案。对住院病案临床特征、缺陷原因、歧义病案危险因素进行统计分析。结果全年出院病案4124份,其中歧义病案共77份,占比1.87%。与非歧义组比较,更多的歧义组患者采用自费方式,经历转科和较长时间住院。歧义组患者手术和外伤占比更高,但肿瘤患者占比较低。由于DRG分组规则原因入歧义组64份(83.1%),为首要直接原因。二元Logistic回归提示,自费医疗(OR=2.2)、转科(OR=4.8)、住院≥7 d(OR=3.1)、外伤(OR=15.0)、总费用>2万元(OR=1.7)是歧义病案产生的危险因素(P<0.05),而肿瘤疾病是保护因素(OR=0.6,P<0.05)。结论歧义病案的产生涉及到临床诊疗、医院管理、卫生政策等诸多方面,对医院绩效和医保基金都具有重要影响。加强医院管理水平,提升信息化系统质量,促进医-管-患三方协调沟通,是减少歧义病案的有效途径。Objective To analyze the reasons and influencing factors of ambiguous medical records,and propose targeted intervention strategies.Methods The medical records discharged from the Department of Otolaryngology,Head and Neck Surgery of a large Class III hospital in Xi’an from January 2023 to December 2023 were retrospectively collected,and the medical records groups and ambiguous medical records were screened through the DRG information platform.The clinical features,defect causes and risk factors of ambiguous cases were analyzed statistically.Results There were 4124 discharged cases in the year,of which 77 were ambiguous cases,accounting for 1.87%.Compared with the non-ambiguous group,more patients in the ambiguous group adopted a self-funded approach,experienced a transfer and a longer hospital stay.The proportion of surgery and trauma in ambiguous group was higher,but the proportion of tumor patients was lower.Due to DRG grouping rules,64 cases(83.1%)were divided into ambiguous groups,which was the primary direct cause.Binary Logistic regression indicated that self-paid medical treatment(OR=2.2),transfer(OR=4.8),hospitalization≥7 days(OR=3.1),trauma(OR=15.0),and total cost>20000 yuan(OR=1.7)were the risk factors for ambiguous disease cases(P<0.05),while tumor disease was the protective factor(OR=0.6,P<0.05).Conclusion The emergence of ambiguous medical records involves many aspects such as clinical diagnosis and treatment,hospital management,health policy and so on,which has an important impact on hospital performance and medical insurance fund.Only by strengthening the level of hospital management,improving the quality of information system,and promoting the coordination and communication between doctors,management and patients,can we effectively reduce the occurrence of ambiguous medical records.

关 键 词：诊断相关分组 歧义病案 质量控制 编码 

分 类 号：R197.323.1[医药卫生—卫生事业管理]