Classification Error Analysis of Major Gynecological Surgical Procedures Based on ADRG Enrollment
Objectives This study aims to analyze the problems in the ICD classification of ADRG enrollment errors in a certain hospital's gynecology department and improve the data quality on the front page of inpatient medical records.According to the grouping details of 4,683 discharged patients from the Department of Gynecology of a certain hospital from January 1,2020 to December 31,2022,fed back by the Sichuan Province DRG Evaluation Management System,there were a total of 23 specialist ADRGs,and 50 cases were randomly selected from each ADRG group.A total of 1150 cases were retrospectively analyzed.The accuracy of the main diagnosis,main surgical operation classification,and ADRG enrollment on the front page of the inpatient medical record was checked,and wrong ICD codes were corrected.The differences in ADRG enrollment before and after the correction were checked,and the ICD classification defects that cause ADRG enrollment errors were analyzed.Data sorting,classification,screening,and comparison on defect issues were conducted based on Excel 2017,and the causes of classified defects were analyzed.Results Through self-examination and self-correction,it was found that 107 medical records were found to have errors in ADRG enrollment and had no major diagnostic classification defects.There were 21 defects in the DRGs grouping scheme,and 86 defects in the classification of major surgical operations,accounting for 80.37%of the total defect cases.Defects in the classification of major surgical operations included:clinicians missed filling in 14 major operations,31 names were filled in irregularly,and 23 major surgical operations were incorrectly selected;coders missed coding 5 operations,and coders incorrectly coded 13 operations.Conclusions The gynecological ADRG enrollment error is mainly caused by defects in the classification of major surgical operations,including errors in filling in the front page of the resident medical records of clinicians and issues with the professional skills of coders.Hospitals should continue to carry out special quality control on the front page of inpatient medical records,strengthen standardized training for clinicians to fill in medical record information,strengthen coders'awareness of responsibility,accumulate clinical knowledge,and ensure the quality of data on the front page of inpatient medical records.At the same time,hospitals should promote the update and improvement of the DRGs grouping plan to provide an accurate data basis for the evaluation of specialist medical service capabilities and DRGs payment.