| Abstract |
Objective To analyze the defects in the homepage of a hospitals low-rate medical records, and to propose improvement measures for the existing problems. Methods A hospital was grouped by DRGs from the Municipal Social Security Bureau and enrolled 486 low-rate medical records from July to December 2021. A total of 162 medical records were selected by the equidistant random sampling method for self-examination. Self-correction and retrospective analysis. Results There were 66 defects in the 162 medical records, among which the doctors "wrongly filled in the wrong choice for the main diagnosis", "wrongly filled in the wrong choice for the main surgery", "wrongly filled in the wrong choice for the main diagnosis and operation", "wrongly filled in the wrong filling in the other diagnosis or surgery", accounting for The ratios were 31.82%, 6.06%, 6.06%, and 7.57% in sequence; the proportions of coders in the order of "wrong coding of main diagnosis", "wrong coding of main surgery", "wrong coding of main diagnosis and surgery", "miscoding of other diagnoses or surgery", etc. The percentages were 19.70%, 13.64%, 6.06%, and 9.09%; Conclusion Hospitals should improve doctors to fill in the requirements for diagnosis and surgical operation, train ICD and DRGs knowledge; improve the coding level, work responsibility and attitude of coders to improve the accuracy of ICD coding.
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