DRGs分组中QY病案首页内涵质量缺陷分析

Abstract

目的 分析某院DRGs分组进入QY(歧义)组病案首页数据填报过程中存在的问题,提出解决对策,持续改进提高病案数据质量.方法 北京市卫生计生委信息中心对各三级医院2016年7月-2017年6月上报HQMS数据平台并经DRGs分组后的病案,进行住院病案首页督导检查.某院从北京市卫生计生委信息中心反馈的HQMS数据平台中抽取130份QY病案, 进行自查自纠和回顾性分析,并以信息中心本次督导检查中所提供的10份QY病案为例,对缺陷问题进行举例、归类、统计和分析.结果 某院经过自查自纠发现,130份QY病案产生的原因均与编码员编码能力和病案阅读能力等有关,缺陷率100%.编码员主要诊断选择错误3份,编码员对疾病含义不了解造成编码错误4份,编码员凭经验编码错误1份,编码员疾病和手术编码同时错误1份,编码员手术编码错误3份,临床医师手术填报错误2份,主要诊断填报错误3份.结论 QY病案的问题实质上就是编码能力和水平的问题.病案信息管理者应加强病案管理和培训方法,提升编码能力,切实提高病案首页填写质量,确保病案首页数据和DRGs分组数据的准确性.

Objectives To analyze the problems existing in the data filling in the front page of QY (ambiguity) group of the DRG group in a hospital, and propose solutions to improve the quality of medical records. Methods The information center of Beijing municipal health and family planning commission reported the HQMS data platform from July, 2016 to June, 2017, and carried out the front page supervision and inspection of the hospital medical records after the DRGs group. A hospital from the Beijing municipal health and family planning commission information center feedback HQMS pump 130 QY data platform medical record, self-check and were retrospectively analyzed, and the information center to check the supervision provided by October QY medical record, for example, the defects, for example, classification, statistics and analysis. Results In a certain hospital, 130 QY medical records were found to be related to the coding ability of the coder and the reading ability of the case, and the defect rate was 100%. To check the supervision of accurate sampling 10 QY records as an example, the coders in 3 main diagnosis wrong choice and coders didn't understand the meaning of disease coding errors caused by 4, 1 coders coding errors with experience, coders disease and 1 surgery coding errors at the same time, coders surgery in 3 coding errors and clinicians surgery 2 fill in error, the main diagnostic errors in 3 is allowed. Conclusions The problem of QY medical records was essentially the problem of coding ability and level. For QY medical record front page content quality defects analysis and problem's reason, medical record information managers should strengthen medical record management and training methods, promote coding ability, effectively raise the quality of medical record front page to fill in, to ensure the accuracy of the medical record front page data and DRGs grouped data.