CN112349400B - Medical record coding quality control method based on DRG principle - Google Patents
Medical record coding quality control method based on DRG principle Download PDFInfo
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Abstract
The invention discloses a medical record coding quality control method based on a DRG principle. Belongs to the technical field of medical records coding quality control, and provides a medical records coding quality control system which can effectively detect and diagnose the matching degree of operations and has good accuracy. The realization process of the medical records coding quality control method is as follows: extracting basic information, diagnosis list, operation list, expense item list, missed operation detail map and missed operation sub-view map of patient; correlating the expense item details, the operation list, the basic information and the diagnosis list, and pushing out the original grouping, grouping parameters, the original primary diagnosis, the original primary operation, the original primary diagnosis and the original primary operation of the patient; and calculating a surgical missing list.
Description
Technical Field
The invention relates to the technical field of medical record coding quality control, in particular to a medical record coding quality control method based on a DRG principle.
Background
The medical records front page is raised to important evidence paid by medical insurance DRG from traditional medical document data, and is also an important source of 7 indexes in 55 indexes of national assessment hospitals, the medical records front page has influence on the operation and management of the hospitals, the medical records front page management is standardized, and the quality control of the medical records front page is enhanced to be an important proposition. The existing medical records have poor coding quality control accuracy.
Disclosure of Invention
The invention aims to solve the defect of poor quality control accuracy of the conventional medical record coding, and provides a medical record coding quality control method based on a DRG principle, which can effectively detect and diagnose the matching degree of an operation and has good medical record coding quality control accuracy.
In order to achieve the above purpose, the invention is realized by the following technical scheme:
the medical record coding quality control method based on the DRG principle is characterized by comprising the following implementation processes:
step S1, basic information, diagnosis list, operation list, expense item detail, missed operation detail mapping table and missed operation sub-order mapping table of a patient are respectively extracted;
step S2, associating the details of the expense items, the operation list, the basic information and the diagnosis list, and pushing out the original group, the group parameters, the original diagnosis, the original operation, the original diagnosis and the original operation of the patient;
step S3, calculating an operation missing list;
associating the details of the expense items of the patient with the missed surgical sub-order mapping list, and pushing out the missed surgical sub-order list of the patient;
then comparing the patient missed surgical sub-order list with the patient surgical list, and judging whether the information on the patient missed surgical sub-order list exists in the patient surgical list or not;
if the information on the patient missed surgical sub-order list exists in the patient's surgical list, indicating that the patient has no missed surgery;
if the information on the missed surgical sub-order list of the patient does not exist in the surgical list of the patient, indicating that the patient has a missed surgery, associating the missed surgical sub-order list with the missed surgical detail mapping list, and searching out a complete surgical code;
discarding if no complete surgical code exists;
if a complete surgical code exists, then determine if the complete surgical code is a prior surgery?
If the operation is a preliminary operation, the quality inspection result is a missing operation;
if the operation is not the preliminary operation, the step S4 is entered;
step S4, taking the data of the original group, the group parameters, the original diagnosis, the original operation and the missing operation of the patient as the original data of the patient;
inputting the patient's raw data into a grouper, performing a predictive grouping as an original grouping, and determining whether the original grouping is medical or surgical?
If the original group is internal medicine, entering step S5;
if the original group is surgical, go to step S10;
if the original packet is no packet, ending the quality inspection;
step S5, judging whether the patient has an operation to be performed or not, and also judging whether the patient has an absent operation to be performed or not;
step S6, if no operation is to be performed, finishing quality inspection;
step S7, if the operation to be performed exists, judging all diagnoses of the patient once to obtain a main diagnosis of the patient; and determining whether the patient's primary diagnosis is of highest severity among all diagnoses;
step S8, if the main diagnosis of the patient is the most serious in all diagnoses, the quality inspection result is correct, and the quality inspection is finished;
step S9, if the main diagnosis of the patient is not the most serious of all diagnoses, the quality inspection result is the main diagnosis with wrong selection;
step S10, fixing the main diagnosis of the patient, sequentially taking out all operations as main operations and other operations as secondary operations according to the filling sequence, carrying out prediction grouping, finding out groups more accurate than the original grouping, and putting the groups into a set;
step S11, if the set is empty, fixing the primary operation, sequentially taking out diagnoses as primary diagnoses, taking other diagnoses as secondary diagnoses, and carrying out other operations in the same way as the step S7;
and step S12, if the set is not empty, obtaining a prompt according to the condition that the selected main operation comprises the missing operation as the condition.
The scheme can effectively detect and diagnose the matching degree of the operation, and the medical record coding quality control accuracy is good.
Preferably, in step S7, when there is an operation to be performed, it is first determined whether the main diagnosis, the missing operation, and the operation group are surgical groups, and if not, the diagnosis is sequentially taken out as the main diagnosis and then re-determined until it is determined as a surgical group; if the surgical group is the surgical group, judging whether the main diagnosis, the missing surgery and the surgery group are invalid filtering groups,
if the filter packet is not invalid, sequentially taking out diagnosis as a main diagnosis and then re-judging until the filter packet is judged to be invalid; if the filtering group is invalid, judging whether the total cost of the main diagnosis, the missing operation and the operation group is lower than 0.5 yuan,
if the total cost is lower than 0.5 yuan, judging whether the main diagnosis, the missing operation and the operation grouping are greater than the number of the queue grouping points, if so, putting the main diagnosis, the missing operation and the operation grouping into a set, and judging whether the set queue is greater than 0;
if the aggregate queue is greater than 0, judging whether the main operation is consistent, whether the main diagnosis is consistent and whether the main operation is absent operation, if the main operation is consistent, the main diagnosis is consistent and the main operation is absent operation, issuing a case error prompt 2,
if the aggregate queue is equal to 0, judging whether the primary operation, the missing operation and the secondary diagnosis group are surgical, if not, taking out the diagnosis in sequence as the primary diagnosis and then judging again until the surgical group is judged; if the surgical operation is surgical operation, judging whether the primary operation, the missing operation and the secondary diagnosis grouping are invalid filtering grouping or not;
if the primary operation, the missing operation and the secondary diagnosis group are invalid filtering groups, judging whether the cost is lower than 0.5 yuan or not, if the cost is lower than 0.5 yuan, judging whether the primary operation, the missing operation and the secondary diagnosis group are larger than the original group point,
if the number of the primary group points is larger than the number of the primary group points, judging whether the primary operation is consistent, whether the primary diagnosis is consistent and whether the primary operation is absent operation, and if the primary operation is consistent, whether the primary diagnosis is consistent and whether the primary operation is absent operation, sending a medical case error prompt 1.
Preferably, step S8, comparing the primary diagnosis with the highest patient severity with the primary diagnosis severity of the patient;
if the severity of the main diagnosis with the highest patient severity is more than one time of the severity of the original main diagnosis of the patient, judging that the quality inspection result at the moment is a high-reliability result;
if the severity of the primary diagnosis with the highest patient severity is less than one time of the severity of the primary diagnosis of the patient, the quality inspection result at the moment is judged to be a general reliable result.
The invention can achieve the following effects:
the invention can effectively detect and diagnose the matching degree of the operation from the aspects of DRG grouping algorithm and medical treatment, improves the quality control of the medical record coding, and has good accuracy of the medical record coding quality control.
Drawings
FIG. 1 is a schematic flow chart of a part of the present invention.
FIG. 2 is a schematic flow chart of a part of the present invention.
Detailed Description
The invention is further described below with reference to the drawings and examples.
The medical records coding quality control method based on the DRG principle, referring to fig. 1 and 2, is realized as follows:
step S1, basic information, diagnosis list, operation list, expense item detail, missed operation detail mapping table and missed operation sub-order mapping table of a patient are respectively extracted;
step S2, associating the details of the expense items, the operation list, the basic information and the diagnosis list, and pushing out the original group, the group parameters, the original diagnosis, the original operation, the original diagnosis and the original operation of the patient;
step S3, calculating an operation missing list;
associating the details of the expense items of the patient with the missed surgical sub-order mapping list, and pushing out the missed surgical sub-order list of the patient;
then comparing the patient missed surgical sub-order list with the patient surgical list, and judging whether the information on the patient missed surgical sub-order list exists in the patient surgical list or not;
if the information on the patient missed surgical sub-order list exists in the patient's surgical list, indicating that the patient has no missed surgery;
if the information on the missed surgical sub-order list of the patient does not exist in the surgical list of the patient, indicating that the patient has a missed surgery, associating the missed surgical sub-order list with the missed surgical detail mapping list, and searching out a complete surgical code;
discarding if no complete surgical code exists;
if a complete surgical code exists, then determine if the complete surgical code is a prior surgery?
If the operation is a preliminary operation, the quality inspection result is a missing operation;
if the operation is not the preliminary operation, the step S4 is entered;
step S4, taking the data of the original group, the group parameters, the original diagnosis, the original operation and the missing operation of the patient as the original data of the patient;
inputting the patient's raw data into a grouper, performing a predictive grouping as an original grouping, and determining whether the original grouping is medical or surgical?
If the original group is internal medicine, entering step S5;
if the original group is surgical, go to step S10;
if the original packet is no packet, ending the quality inspection;
step S5, judging whether the patient has an operation to be performed or not, and also judging whether the patient has an absent operation to be performed or not;
step S6, if no operation is to be performed, finishing quality inspection;
step S7, if the operation to be performed exists, judging all diagnoses of the patient once to obtain a main diagnosis of the patient; and determining whether the patient's primary diagnosis is of highest severity among all diagnoses;
step S8, if the main diagnosis of the patient is the most serious in all diagnoses, the quality inspection result is correct, and the quality inspection is finished;
step S9, if the main diagnosis of the patient is not the most serious of all diagnoses, the quality inspection result is the main diagnosis with wrong selection;
step S10, fixing the main diagnosis of the patient, sequentially taking out all operations as main operations and other operations as secondary operations according to the filling sequence, carrying out prediction grouping, finding out groups more accurate than the original grouping, and putting the groups into a set;
step S11, if the set is empty, fixing the primary operation, sequentially taking out diagnoses as primary diagnoses, taking other diagnoses as secondary diagnoses, and carrying out other operations in the same way as the step S7;
and step S12, if the set is not empty, obtaining a prompt according to the condition that the selected main operation comprises the missing operation as the condition.
In step S7, when there is an operation to be performed, it is first determined whether the main diagnosis, the missing operation, and the operation group are surgical groups, and if not, the diagnosis is sequentially taken out as the main diagnosis and then re-determined until it is determined as a surgical group; if the surgical group is the surgical group, judging whether the main diagnosis, the missing surgery and the surgery group are invalid filtering groups,
if the filter packet is not invalid, sequentially taking out diagnosis as a main diagnosis and then re-judging until the filter packet is judged to be invalid; if the filtering group is invalid, judging whether the total cost of the main diagnosis, the missing operation and the operation group is lower than 0.5 yuan,
if the total cost is lower than 0.5 yuan, judging whether the main diagnosis, the missing operation and the operation grouping are greater than the number of the queue grouping points, if so, putting the main diagnosis, the missing operation and the operation grouping into a set, and judging whether the set queue is greater than 0;
if the aggregate queue is greater than 0, judging whether the main operation is consistent, whether the main diagnosis is consistent and whether the main operation is absent operation, if the main operation is consistent, the main diagnosis is consistent and the main operation is absent operation, issuing a case error prompt 2,
if the aggregate queue is equal to 0, judging whether the primary operation, the missing operation and the secondary diagnosis group are surgical, if not, taking out the diagnosis in sequence as the primary diagnosis and then judging again until the surgical group is judged; if the surgical operation is surgical operation, judging whether the primary operation, the missing operation and the secondary diagnosis grouping are invalid filtering grouping or not;
if the primary operation, the missing operation and the secondary diagnosis group are invalid filtering groups, judging whether the cost is lower than 0.5 yuan or not, if the cost is lower than 0.5 yuan, judging whether the primary operation, the missing operation and the secondary diagnosis group are larger than the original group point,
if the number of the primary group points is larger than the number of the primary group points, judging whether the primary operation is consistent, whether the primary diagnosis is consistent and whether the primary operation is absent operation, and if the primary operation is consistent, whether the primary diagnosis is consistent and whether the primary operation is absent operation, sending a medical case error prompt 1.
Step S8, comparing the main diagnosis with the highest patient severity with the original main diagnosis of the patient;
if the severity of the main diagnosis with the highest patient severity is more than one time of the severity of the original main diagnosis of the patient, judging that the quality inspection result at the moment is a high-reliability result;
if the severity of the primary diagnosis with the highest patient severity is less than one time of the severity of the primary diagnosis of the patient, the quality inspection result at the moment is judged to be a general reliable result.
The invention can effectively detect and diagnose the matching degree of the operation, and the accuracy of the medical record coding quality control is good.
Claims (1)
1. The medical record coding quality control method based on the DRG principle is characterized by comprising the following implementation processes:
step S1, basic information, diagnosis list, operation list, expense item detail, missed operation detail mapping table and missed operation sub-order mapping table of a patient are respectively extracted;
step S2, associating the details of the expense items, the operation list, the basic information and the diagnosis list, and pushing out the original group, the group parameters, the original diagnosis, the original operation, the original diagnosis and the original operation of the patient;
step S3, calculating an operation missing list;
associating the details of the expense items of the patient with the missed surgical sub-order mapping list, and pushing out the missed surgical sub-order list of the patient;
then comparing the patient missed surgical sub-order list with the patient surgical list, and judging whether the information on the patient missed surgical sub-order list exists in the patient surgical list or not;
if the information on the patient missed surgical sub-order list exists in the patient's surgical list, indicating that the patient has no missed surgery;
if the information on the missed surgical sub-order list of the patient does not exist in the surgical list of the patient, indicating that the patient has a missed surgery, associating the missed surgical sub-order list with the missed surgical detail mapping list, and searching out a complete surgical code;
discarding if no complete surgical code exists;
if the complete surgical code exists, judging whether the complete surgical code is a prior surgery or not,
if the operation is a preliminary operation, the quality inspection result is a missing operation;
if the operation is not the preliminary operation, the step S4 is entered;
step S4, taking the data of the original group, the group parameters, the original diagnosis, the original operation and the missing operation of the patient as the original data of the patient;
inputting the original data of the patient into a packetizer, performing a predictive packet as an original packet, and judging whether the original packet is medical or surgical,
if the original group is internal medicine, entering step S5;
if the original group is surgical, go to step S10;
if the original packet is no packet, ending the quality inspection;
step S5, judging whether the patient has an operation to be performed or not, and also judging whether the patient has an absent operation to be performed or not;
step S6, if no operation is to be performed, finishing quality inspection;
step S7, if the operation to be performed exists, judging all diagnoses of the patient once to obtain a main diagnosis of the patient; and determining whether the patient's primary diagnosis is of highest severity among all diagnoses;
step S8, if the main diagnosis of the patient is the most serious in all diagnoses, the quality inspection result is correct, and the quality inspection is finished;
step S9, if the main diagnosis of the patient is not the most serious of all diagnoses, the quality inspection result is the main diagnosis with wrong selection;
step S10, fixing the main diagnosis of the patient, sequentially taking out all operations as main operations and other operations as secondary operations according to the filling sequence, carrying out prediction grouping, finding out groups more accurate than the original grouping, and putting the groups into a set;
step S11, if the set is empty, fixing the primary operation, sequentially taking out diagnoses as primary diagnoses, taking other diagnoses as secondary diagnoses, and carrying out other operations in the same way as the step S7;
step S12, if the set is not empty, obtaining a prompt according to the condition that the selected main operation comprises the missing operation as the condition;
in step S7, when there is an operation to be performed, it is first determined whether the main diagnosis, the missing operation, and the operation group are surgical groups, and if not, the diagnosis is sequentially taken out as the main diagnosis and then re-determined until it is determined as a surgical group; if the surgical group is the surgical group, judging whether the main diagnosis, the missing surgery and the surgery group are invalid filtering groups,
if the filter packet is not invalid, sequentially taking out diagnosis as a main diagnosis and then re-judging until the filter packet is judged to be invalid; if the filtering group is invalid, judging whether the total cost of the main diagnosis, the missing operation and the operation group is lower than 0.5 yuan,
if the total cost is lower than 0.5 yuan, judging whether the main diagnosis, the missing operation and the operation grouping are greater than the number of the queue grouping points, if so, putting the main diagnosis, the missing operation and the operation grouping into a set, and judging whether the set queue is greater than 0;
if the aggregate queue is greater than 0, judging whether the main operation is consistent, whether the main diagnosis is consistent and whether the main operation is absent operation, if the main operation is consistent, the main diagnosis is consistent and the main operation is absent operation, issuing a case error prompt 2,
if the aggregate queue is equal to 0, judging whether the primary operation, the missing operation and the secondary diagnosis group are surgical, if not, taking out the diagnosis in sequence as the primary diagnosis and then judging again until the surgical group is judged; if the surgical operation is surgical operation, judging whether the primary operation, the missing operation and the secondary diagnosis grouping are invalid filtering grouping or not;
if the primary operation, the missing operation and the secondary diagnosis group are invalid filtering groups, judging whether the cost is lower than 0.5 yuan or not, if the cost is lower than 0.5 yuan, judging whether the primary operation, the missing operation and the secondary diagnosis group are larger than the original group point,
if the number of the primary group points is larger than the number of the primary group points, judging whether the primary operation is consistent, whether the primary diagnosis is consistent and whether the primary operation is a missing operation, and if the primary operation is consistent, the primary diagnosis is consistent and the primary operation is the missing operation, sending a medical record error prompt 1;
step S8, comparing the main diagnosis with the highest patient severity with the original main diagnosis of the patient;
if the severity of the main diagnosis with the highest patient severity is more than one time of the severity of the original main diagnosis of the patient, judging that the quality inspection result at the moment is a high-reliability result;
if the severity of the primary diagnosis with the highest patient severity is less than one time of the severity of the primary diagnosis of the patient, the quality inspection result at the moment is judged to be a general reliable result.
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| CN112992366B (en) * | 2021-03-01 | 2024-05-24 | 袁素华 | ICD (information and control device) coding artificial intelligence auditing quality control mode and system based on medical insurance disease seed payment |
| CN114155968A (en) * | 2021-04-29 | 2022-03-08 | 深圳市康比特信息技术有限公司 | Method for establishing mapping relation, and method and equipment for auditing surgical operation |
| CN113823414B (en) * | 2021-08-23 | 2024-04-05 | 杭州火树科技有限公司 | Main diagnosis and main operation matching detection method, device, computing equipment and storage medium |
| CN113496410A (en) * | 2021-09-10 | 2021-10-12 | 武汉金豆医疗数据科技有限公司 | DRG payment mode-based violation monitoring method and device |
| CN114974600B (en) * | 2022-03-04 | 2023-09-29 | 中国环球租赁有限公司 | Case grouping method, device, electronic equipment and medium |
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