摘要
Abstract
Objective To analyze the high-rate cases based on DRGs payment in a surgery department of a hospital in Foshan,and to explore the reasons for mistakenly in high-rate cases,and propose improvement measures to avoid hospital economic losses.Mehtods Eighty-four high-rate cases were collected from the Department of Thyroid-Breast-Thoracic Surgery and Burn Plastic Surgery of a hospital(removed transferred cases),with the settlement time ranging from April to September 2023.Self-correction and retrospective analysis were carried out on the defect types of diagnosis and surgical operation filling and coding in the first page of the medical records,which were recorded and classified with Excel2003.Results Of the 84 high-rate cases,26 medical records were mistakenly compiled by coders,the main diagnosis errors accounted for 46.15％in 12 case,the main operation accounted for 34.62％in 9 cases,the main diagnosis and main operation accounted for 11.54％in 3 cases,the other diagnoses or other operations accounted for 7.69％in 2 cases.Among the 26 cases of wrong medical records,15 cases were mistakenly compiled by doctors,the main diagnosis accounted for 20.00％in 2 cases,the main operation accounted for 60.00％in 9 cases,the main diagnosis and main operation accounted for 13.33％in 2 cases,the other diagnosis or other operation accounted for 6.67％in 1 case.Conclusion The main reason for mistakenly in high-rate cases is whether the coding and filling of the main diagnosis and the main operation are accurate.The hospital should strengthen the writing quality of diagnosis and surgical operation and the quality of ICD coding to ensure the correct inclusion of medical records and avoid the economic loss caused by entering the high-rate cases group.关键词
DRGs/高倍率病案/诊断与手术操作/编码缺陷Key words
DRGs/High-rate cases/Diagnosis and surgery operation/Coding defect分类
医药卫生
