Analysis on Factors Related to Abnormal Enrollment of Inpatient Records in Spinal Department
Objectives To reveal the main causes of ambiguous cases in the department of spine,and put forward corresponding corrective measures and suggestions for improvement,in order to improve the success rate of DRG enrollment.Methods From January 1st,2023 to June 30th,2023,4318 medical records uploaded to the DRG payment management system and grouped by the grouping device were collected,and 197 ambiguous medical records were screened out.Senior clinical quality control physicians and senior coders were organized to review and analyze the causes of ambiguous medical records.Results The incidence of ambiguous cases in the department of spine accounted for 4.56%of the total cases.In addition,among the 197 cases of ambiguity,major diagnosis selection errors accounted for 5.07%,major surgical procedure selection errors accounted for 2.03%,major surgical coding errors accounted for 7.11%,and CHS-DRG grouping scheme defects accounted for 85.79%.Conclusions Through the analysis of ambiguous medical records,the main causes of ambiguous medical records were the defects of grouping scheme,the lack of clinical medical knowledge of coders,and the failure of clinicians to correctly grasp the principles of major diagnosis and major surgical operation selection.Therefore,clinicians should strengthen the study and research of DRG related knowledge,and coders should constantly improve their business capabilities,strengthen information construction,and help the high-quality development of DRG.
Ambiguous medical recordsSpinal departmentCHS-DRG grouping schemeMain diagnosisMain surgical procedures
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NSTL
万方数据
