关键词: 疾病诊断相关分组, 国际疾病分类, 歧义病案

Abstract: Objective To reduce the coding errors, improve the coding quality and improve the enrollment rate of DRGs through the analysis of the ambiguous medical records of a hospital. Methods Through a retrospective analysis of a total of 71 ambiguous medical records from September 2018 to April 2019 in a hospital, the medical records were read by three senior coders, analyzed according to the classification of disease and operation classification coding principle through applying The International Statistical Classification of Diseases and Related Health Problems 10th Revision and International Classification of Diseases Clinical Modification of 9th Revision operations and procedures. Microsoft Excel was used to categorize and summarize error problems, discover common coding error issues, analyze the error reasons and improvement measures from the coding perspective. Results Coders were not good at using dictionaries during coding, lack of coding and clinical knowledge, insufficient communication with the clinic were theprimary cause to theunincorporated of medical records. Conclusion Coders should pay attention to all aspects of coding to improve coding quality, learn more about clinical knowledge, read the medical records carefully, look up the dictionary to check the exact code, communicate with the clinician again, through a series of standardization processes to effectively reduce error coding, improve coding level, ensure the accuracy of DRGs grouping data.

Key words: diagnosis related groups, international classification of diseases, ambiguous medical records