首页|基于ADRG人组的妇科主要手术操作分类缺陷分析

基于ADRG人组的妇科主要手术操作分类缺陷分析

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目的 分析某院妇科ADRG入组误差ICD分类中的问题,提高住院病案首页数据质量.方法 根据四川省DRGs评价管理系统反馈的2020年1月1日-2022年12月31日某院妇科4683位出院患者的分组明细,共23个专科ADRG,各ADRG组随机抽取50例,合计1150份病案进行回顾性分析.检查住院病案首页主要诊断、主要手术操作分类及ADRG入组的准确性,修正错误的ICD编码,核对修正前后的ADRG入组差异,分析致ADRG入组误差的ICD分类缺陷问题,对缺陷问题基于Excel 2017进行数据整理、分类和筛选、比对,并分析分类缺陷的原因.结果 通过自查自纠发现107份病案ADRG人组有误,无主要诊断分类缺陷,DRGs分组方案缺陷21份,而主要手术操作分类缺陷86份,占总缺陷病案80.37%.主要手术操作分类缺陷包括:临床医师漏填主要手术14份,名称填写不规范31份,主要手术操作选择错误23份;编码员漏编码5份,编码员错误编码13份.结论 妇科ADRG入组误差主因是主要手术操作分类缺陷所致,包括临床医师住院病案首页填写错误和编码员专业技能问题.应持续开展住院病案首页专项质控,加强临床医师病案信息填写规范培训,强化编码员责任意识,积累临床知识,保证住院病案首页数据质量;同时促进DRGs分组方案的更新完善,为专科医疗服务能力评价与DRGs付费提供准确的数据基础.
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.

DRGsADRGClassification of operationCoding quality

杨佳雯、陈俐、陈阳、王浩、唐美玲、许珠灵

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四川省成都市第三人民医院医院质量评价与病案管理部,四川省,成都市,610000

安岳县人民医院病案统计科,四川省,资阳市,642350

成都市第七人民医院病案统计科,四川省,成都市,610000

DRGs ADRG 手术操作分类 编码质量

四川省医院协会医院管理科研专项

YG2342

2024

中国病案
中国医院协会

中国病案

CSTPCD
影响因子:1.197
ISSN:1672-2566
年,卷(期):2024.25(3)
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