1.Department of Medical Records and Statistics, Guangdong General Hospital's Nanhai Hospital (Second People's Hospital of Nanhai District of Foshan), Foshan 528251, China;
2.Orthopedics and Traumatology Department of Traditional Chinese Medicine, Guangdong General Hospital's Nanhai Hospital (Second People's Hospital of Nanhai District of Foshan);
3.Medical Section, Guangdong General Hospital's Nanhai Hospital (Second People's Hospital of Nanhai District of Foshan)
Abstract：Objective To analyze the defective problems existing in the data filling in the front page of medical records of the high rate cases whose cost were more than twice the average cost based on DRGs payment in a hospital, and to put forward improvement measures.Methods The hospital received the high rate cases which were grouped by DRGs and settled expenses between January, 2018 and June, 2018 from the Social Security Bureau's feedback. Combined with DRGs payment mode, under the guidance of the diagnosis operation selection standard announced by the Health Development Planning Commission and the Principles of International Classification of Diseases, selfcheck and retrospective analysis were conducted, and the defects were classified and counted with 6 cases of high rate paying.Results Totally 111 of 526 high rate cases had defect problems related to clinicians and coders, with defective rate 21.11%, and among them, 47, 20, 12 and 29 cases were clinicians' main diagnostic error selection, main operation error selection , main diagnosis and operation error selection, and missing of diagnosis or operation, respectively. The percentage of errors was 42.34%, 18.02%, 10.81% and 26.13% respectively. The coders' main diagnosis coding error and main surgical coding error were 2 and 1 cases respectively, with error rate 1.8% and 0.9% respectively.Conclusion The high rate paying cases caused by the defects of the filling diagnosis and operation and the coding defects on the front page of medical records were closely related to the quality of filling by clinicians and the coding level of coders. Effective measures are to train clinicians to correctly select diagnosis and operation, improve coders' professional skills, and optimize coders' work, so as to reduce high rate cases caused by defective problems.
梁景星,赵跃宝,黄勇,吴跃文,黄晓琳,伦演荭,叶铭坤,杨红娟,吴晓敏,谢丽玲,周婷婷. 基于DRGs付款下高倍率病例的病案首页诊断与手术操作填写和编码缺陷分析[J]. 中国医院统计, 2019, 26(4): 307-310.
Liang Jingxing, Zhao Yuebao, Huang Yong, Wu Yuewen, Huang Xiaolin, Lun Yanhong, Ye Mingkun, Yang Hongjuan, Wu Xiaomin, Xie Liling, Zhou Tingting. Diagnosis and operation filling and coding defect of the first page of high rate paying cases based on DRGs payment. journal1, 2019, 26(4): 307-310.
