Analysis of the factors affecting ambiguous medical records in DRGs
10.3760/cma.j.issn.1000-6672.2015.11.024
- VernacularTitle:DRGs应用中歧义病案的影响因素分析
- Author:
Ya LIU
;
Xiaojuan LI
;
Yue WANG
;
Teng FEI
;
Wenjing ZHANG
- Publication Type:Journal Article
- Keywords:
DRGs;
International code of diseases(ICD);
Home page of medical record;
Logistic regression analysis
- From:
Chinese Journal of Hospital Administration
2015;31(11):875-878
- CountryChina
- Language:Chinese
-
Abstract:
Objective Analyze the causes of ambiguous medical records to provide evidence for the DRGs.Methods 268 Ambiguous medical records were selected from 17 751 surgery medical records between 2010 and 2014 based on major diagnosis and major surgery.The single factor Chi-square test was used to study the influence of various inpatient characteristics on the occurrence of ambiguous medical records, and those significant variables were given assignment to find influencing factors of ambiguous medical records by using logistic regression analysis.Results Ambiguous medical records account for 1.51％ of all surgical medical records.Logistic regression analysis results show that such risk factors as discharging from internal medicine, death of patient, transfer between departments, elderly, long time of hospitalization, and tumor patients, as contributing to ambiguous medical records.All the results are statistically significant (P＜0.05), including discharging from which departments (OR=6.595, 95％CI..5.043 ～ 8.625), death of patient (OR=3.787, 95％ CI: 2.611 ～ 5.492) and transfer between departments (OR =2.746, 95％ CI: 2.061 ～ 3.659), which rank important risk factors for ambiguous medical records.Conclusion Analysis of the causes of ambiguous medical records provides important evidences for the hospital to improve its medical record quality management.
