摘要：
Objectives To analyze the problems existing in the selection of principle diagnosis of patients with malignant tumors based on DRGs payment of a hospital, and put forward improvement measures. Methods To conduct verification on each of the copy of medical records of malignant tumors, and record the information included the department, medical record number, question classification and related information combined with the DRGs payment mode and the diagnosis selection standard announced by the Health Development Planning Commission. Then made classification and statistical analysis on the recorded information such as the department, medical record number, defects questions from January 1st to December 31st in 2016.Results There were 4382 cases of medical records cataloging malignant tumors from January 1st to December 31st in 2016, including defects in 1094 cases of medical record front pages, the defect rate was 24.97％. The defects of high top three department of endocrinology respectively(100％), intensive care(88.89％), nephrology(69.07). Less malignant tumor patients in our hospital departments defect rate was significantly higher than the tumor specialized subject. Conclusions The coding of principle diagnosis selection in the front pages of medical records was the basis of the data accuracy of DRGs. It needed not only careful and standard filling of discharged diagnosis among clinicians, and also the coders should reading the medical records carefully, grasp the coding rules well, and strengthen related professional knowledge as well as keep nice communication with the clinicians.%目的 分析基于DRGs付费的某医院恶性肿瘤病案主要诊断选择过程中存在的问题,提出改进方案.方法 对相关恶性肿瘤病案进行逐份核查,结合DRGs付费方式以及卫计委下发的诊断选择标准为指导依据,将科室、病案号、问题分类等相关信息记录在Excel表,统计2016年1月1日-2016年12月31日记录信息,将科室,缺陷问题等相关数据进行归类与统计分析.结果 编目恶性肿瘤病案4382份,其中主要诊断选择缺陷病案首页1094份,缺陷率为24.97％.其中缺陷率较高的科室前三位分别为内分泌科(100％)、重症监护科(88.89％)、肾脏内科(69.07％).较少收治恶性肿瘤患者的科室缺陷率显著高于肿瘤专科.结论 病案首页中主要诊断编码要求编码人员要仔细查阅病案,熟练掌握编码原则,同时还要加强临床相关专业知识,与医师保持良好的沟通.
