The effect of disease nature on operation coding based on DRG analysis system
10.3969/j.issn.1671-332X.2023.12.013
- VernacularTitle:基于DRG分组系统分析疾病性质对手术编码的影响
- Author:
Peishan LIN
1
;
Liangjing LI
;
Wenning REN
Author Information
1. 深圳市人民医院//暨南大学第二临床医学院//南方科技大学第一附属医院 广东深圳 518020
- Keywords:
Surgical procedures;
Nature of the disease;
Unorganized medical records;
DRG enrollment rate
- From:
Modern Hospital
2023;23(12):1852-1855,1860
- CountryChina
- Language:Chinese
-
Abstract:
Objective Based on the problems existing in the DRG grouping of non-enrolled medical records in a tertiary hospital,analyze the impact of disease nature on surgical coding,propose solutions,and continuously improve the quality of med-ical record data.Methods From January to June 2022,the medical records reported to the DRG group in the medical records room were found by the data center platform of the DRG inpatient medical service detection and analysis system,and the number of cases in which the medical records were not included in the DRG group due to the disease nature of the surgical operation name was found,and the defects were cited,classified,counted and analyzed.And the statistical analysis of the cost before and after the revision of the surgical code,and discuss the solution.Results After statistical analysis,it was found that the causes of 377 non enrolled medical records were related to the main diagnosis and surgical procedures,accounting for 85.46%.The main diag-nosis and surgical procedures were 55 cases of mismatched surgical procedure codes due to the nature of the disease.Conclusion The issue of not being included in the medical record is essentially a matter of the nature of the disease and surgical procedures in the main diagnosis.Medical record information managers should strengthen the management and training methods of medical record writing,improve their ability to diagnose and write medical records,ensure the accuracy of medical record homepage data and DRG grouping data,and improve enrollment rates.
