疾病诊断相关分组未入组病案编码分析

目的 通过对某院歧义病案的分析,减少编码错误,提高编码质量,提高疾病诊断相关分组(diagnosis related groups,DRGs)入组率。方法 通过对某院2018年9月至2019年4月共71份歧义病案进行回顾性分析,由3名资深编码员通过阅读病案,查阅疾病和有关健康问题的国际疾病分类(第10次修订本)(the international statistical classification of diseases and related health problems 10th revision,ICD-10)和国际疾病分类第9版临床修订本手术与操作(international classification of diseases clinical modification of 9th revision operations and procedures,ICD-9-CM-3),根据疾病分类和手术操作分类编码原则整理分析,利用Microsoft Excel对错误问题进行分类汇总,发现编码的共性错误问题,从编码角度分析错误原因及改进措施。结果 编码员在编码过程中不善于利用字典,编码知识欠缺,临床知识匮乏,与临床沟通不足等问题是病案未入组的主要原因。结论 编码员应规范编码的查找流程,学习主要诊断选择原则和编码原则,多学习临床知识,认真阅读病案信息,翻阅字典查准编码,核对编码,再与临床医生沟通,通过一系列规范过程切实减少错误编码,提高编码水平,确保DRGs分组数据的准确性。

Analysis of unincorporated cases of diagnosis related groups

Objective To reduce the coding errors, improve the coding quality and improve the enrollment rate of DRGs through the analysis of the ambiguous medical records of a hospital. Methods Through a retrospective analysis of a total of 71 ambiguous medical records from September 2018 to April 2019 in a hospital, the medical records were read by three senior coders, analyzed according to the classification of disease and operation classification coding principle through applying The International Statistical Classification of Diseases and Related Health Problems 10th Revision and International Classification of Diseases Clinical Modification of 9th Revision operations and procedures. Microsoft Excel was used to categorize and summarize error problems, discover common coding error issues, analyze the error reasons and improvement measures from the coding perspective. Results Coders were not good at using dictionaries during coding, lack of coding and clinical knowledge, insufficient communication with the clinic were theprimary cause to theunincorporated of medical records. Conclusion Coders should pay attention to all aspects of coding to improve coding quality, learn more about clinical knowledge, read the medical records carefully, look up the dictionary to check the exact code, communicate with the clinician again, through a series of standardization processes to effectively reduce error coding, improve coding level, ensure the accuracy of DRGs grouping data.