摘要
目的通过分析疾病诊断相关分组(DRGs)系统中的歧义(QY)病案,发现病案首页缺陷问题,提高病案入组率及入组正确率。方法选取广州市某医院2019年部分QY病案,从主要诊断编码是否正确、手术操作编码是否正确、临床主要诊断选择是否正确、临床是否正确填写其他诊断、临床是否正确填写手术操作、是否录入错误等方面评定病案缺陷情况。结果自查QY病案共164份,错误频次73次,缺陷病案59份。主要诊断编码错误率9.15%,手术操作编码错误率6.10%,临床医师主要诊断填写错误率6.10%,临床漏填其他诊断错误率10.37%,临床手术操作填写错误率2.44%,录入错误率10.37%。QY病案产生的原因包括临床医师主要诊断/手术填写存在缺陷,主要诊断/手术编码错误,录入不正确。结论定期分析QY病案能够帮助病案信息管理者发现可能存在的首页数据质量缺陷问题,对医师和编码员的常态化培训可以提升病案正确入组率,改进住院病案首页数据质量。
Objective To find out defects of the first page of medical records, and improve the inclusion rate and accuracy rate of medical records by analyzing the ambiguous(QY) medical records in the DRGs system.Methods Parts of QY medical records from a hospital in Guangzhou in 2019 were selected to evaluate the defects of medical records from the following aspects: whether the main diagnostic codes were correct, whether the surgical operation codes were correct, whether the main clinical diagnosis was correct, whether the other diagnoses were correctly filled in clinically, whether the surgical procedures were correctly filled in clinically, and whether there were input errors.Results Totally 164 QY medical records were self-examined, with 73 errors and 59 defective medical records. The error rate of the main diagnosis code was 9.15%, the error rate of the surgical operation code was 6.10%, the error rate of the clinician′s main diagnosis was 6.10%, the error rate of the clinical omission of other diagnosis was 10.37%, the error rate of the clinical operation was 2.44%, and the error rate of the input was 10.37%. The causes of QY medical record included: the defect of the clinician′s main diagnosis/operation filling, the coding error of the main diagnosis/operation, and the incorrect input.Conclusion Regular analysis of QY medical records can help medical record information managers find possible defects in the quality of home page data and normalized training for physicians and coders can improve the enrollment rate of medical records and the quality of home page data of inpatient medical records.
作者
刘莎
刘骏峰
Liu Sha;Liu Junfeng(The First Affiliated Hospital of Sun Yat-sen University,Guangzhou 510000,China)
出处
《中国医院统计》
2021年第5期452-455,共4页
Chinese Journal of Hospital Statistics
关键词
DRG
歧义病案
主要诊断
病案首页
DRGs
ambiguous medical record
main diagnosis
first page of medical record
