Generation and countermeasures of ambiguous medical records in DRG application
10.3969/j.issn.1671-332X.2025.03.011
- VernacularTitle:DRG应用中歧义病案的产生及对策
- Author:
Shujuan FAN
1
;
Xueli YAN
1
;
Meng ZHANG
1
;
Yuan SHAO
1
;
Wen ZHANG
1
;
Huang ZUO
1
Author Information
1. 西安交通大学第一附属医院 陕西西安 710061
- Publication Type:Journal Article
- Keywords:
Diagnosis related groups;
Ambiguous medical records;
Quality control;
Coding
- From:
Modern Hospital
2025;25(3):371-374
- CountryChina
- Language:Chinese
-
Abstract:
Objective To analyze the reasons and influencing factors of ambiguous medical records,and propose targe-ted intervention strategies.Methods The medical records discharged from the Department of Otolaryngology,Head and Neck Surgery of a large Class Ⅲ hospital in Xi'an from January 2023 to December 2023 were retrospectively collected,and the medical records groups and ambiguous medical records were screened through the DRG information platform.The clinical features,defect causes and risk factors of ambiguous cases were analyzed statistically.Results There were 4 124 discharged cases in the year,of which 77 were ambiguous cases,accounting for 1.87％.Compared with the non-ambiguous group,more patients in the ambig-uous group adopted a self-funded approach,experienced a transfer and a longer hospital stay.The proportion of surgery and trau-ma in ambiguous group was higher,but the proportion of tumor patients was lower.Due to DRG grouping rules,64 cases(83.1％)were divided into ambiguous groups,which was the primary direct cause.Binary Logistic regression indicated that self-paid medical treatment(OR=2.2),transfer(OR=4.8),hospitalization ≥7 days(OR=3.1),trauma(OR=15.0),and total cost＞20 000 yuan(OR=1.7)were the risk factors for ambiguous disease cases(P＜0.05),while tumor disease was the pro-tective factor(OR=0.6,P＜0.05).Conclusion The emergence of ambiguous medical records involves many aspects such as clinical diagnosis and treatment,hospital management,health policy and so on,which has an important impact on hospital per-formance and medical insurance fund.Only by strengthening the level of hospital management,improving the quality of informa-tion system,and promoting the coordination and communication between doctors,management and patients,can we effectively re-duce the occurrence of ambiguous medical records.
