目的:根据诊断相关组(DRG)的要求,分析我院消化内科诊断和程序编码存在的问题,提出改进方案,为有效实施DRGs奠定基础。
方法:以2021年1月1日至2021年12月31日该院消化内科收治的1600名患者的病例-病史标题页为数据来源,以及主要和其他诊断代码,对病例历史标题页中涉及的操作或程序代码进行分类和统计分析。
结果:在2021年在我院接受胃肠内镜检查的531例中,发现编码错误的有66例,未成功的有35例DRG入组,包括14例主要诊断编码不正确的病例(8例DRG入组失败的病例),37例主要操作编码不正确(23例DRG注册不成功),8例主要诊断和主要手术编码错误(4例DRG入组失败)。66例存在编码问题的住院病例分析显示,共有167例存在缺陷,包括36项重大诊断缺陷,其他诊断中的84个缺陷,和47个手术或手术编码缺陷。
结论:疾病诊断和外科手术编码的准确性是DRGs顺利实施的基础。该院医务人员对DRGs编码认知较差,未能认识到病例历史质量的标题页对DRGs系统的重要作用,应提高对DRGs和疾病分类编码知识库的重视程度。此外,编码错误的高发生率,尤其是疾病诊断的遗漏,需要增加对医生和护士的临床知识和DRGs医疗记录要求的培训,从而提高了医疗病例的质量,保证了DRGs信息的准确性。
OBJECTIVE: According to the diagnosis-related group (DRG) requirement, issues of diagnosis and procedure coding in the gastroenterology department of our hospital were analyzed and improvement plans were proposed to lay the foundation for effective implementation of DRGs.
METHODS: The title page of case-history of 1600 patients admitted to the Department of Gastroenterology of this hospital from January 1, 2021 to December 31, 2021 was sampled as a data source, and the primary and other diagnostic codes, operation or procedure codes involved in the title page of case-history were categorized and statistically analyzed.
RESULTS: Of the 531 cases treated with gastrointestinal endoscopy in our hospital in 2021, coding errors were identified in 66 cases and unsuccessful DRG enrollment in 35 cases, including 14 cases with incorrect coding of the primary diagnosis (8 cases with unsuccessful DRG enrollment), 37 cases with incorrect coding of the primary operation (23 cases with unsuccessful DRG enrollment), and 8 cases with incorrect coding of both the primary diagnosis and the primary operation (4 cases with unsuccessful DRG enrollment). Analysis of 66 inpatient cases with coding problems showed a total of 167 deficiencies, including 36 deficiencies in major diagnoses, 84 deficiencies in other diagnoses, and 47 deficiencies in surgery or operation coding.
CONCLUSIONS: The accuracy of coding of disease diagnosis and surgical operation is the basis for the smooth implementation of DRGs. The medical staff of this hospital has poor cognition of DRGs coding and fails to recognize the important role of the title page of case-history quality to DRGs system, and their attention to DRGs and knowledge base of disease classification coding should be improved. In addition, the high incidence of coding errors, especially the omission of disease diagnosis, requires increased training of physicians and nurses on clinical knowledge and requirements for DRGs medical records, thereby improving the quality of medical cases and ensuring the accuracy of DRGs information.