目的：本研究旨在探討病歷書寫完整性對疾病分類編碼正確性與Tw-DRGs分派之影響。方法：以北部某公辦民營地區教學醫院2009年健保住院申報檔與疾病分類檔之DRGs不一致的396例病歷為研究對象，採病歷回溯性再次審查編碼一致性之設計，另以結構式問卷調查醫師與專科護理師對病歷書寫與Tw-DRGs之認知，資料分析包括描述性統計分析與成對樣本T檢定。結果：病歷書寫不完整所致疾病分類編碼不一致原因，主要為主要診斷選擇錯誤197例(51%)，其次為次診斷未編碼86例(21.8%)與主診斷及次診斷編錯代碼各34例(8.6%)。次診斷編錯代碼平均每件DRG相對權重為1.20±0.79，次診斷未編碼為0.78±0.64，病歷書寫完整後之平均每件DRG相對權重，次診斷編錯代碼與未編碼之案件分別為0.86±0.64(減少)與1.09±0.77(增加)，與病歷書寫不完整有顯著差異(p<0.001)。75位問卷回應的醫師及專科護裡師，有68%認為主診斷定義為病人最主要住院的原因，而18.7%則認為是病人最嚴重的診斷。結論：病歷書寫不完整所致之次診斷未編碼對於 Tw-DRGs分派之相對權重有負面的影響，醫院需加強病歷主診斷書寫及病歷書寫完整性之宣導。 Objectives: The present study was conducted to illuminate the effects of medical record integrity on coding and Tw-DRGs assignment. Methods: Retrospective review of 396 medical records submitted DRGs for reimbursement differed from the database of disease coding during the fiscal year 2009 in a district hospital in Northern Taiwan. “Recodes” were carried out and then compared to the original codes. Furthermore, physicians’ and nursing specialists’ perspectives about medical record and Tw-DRGs payment system was gathered via self administered questionnaires. Statistical analysis was performed using descriptive analysis and paired t-test with SPSS. Results: The absence of complete documentation in patient medical records causing the DRG error, the main causes were incorrect principal diagnosis selection (197 records, 51%), missing secondary diagnosis (86 records, 21.8%), incorrect coding of principal diagnosis (34 records, 8.6%) and secondary diagnosis (34 records, 8.6%). The mean (+/- SD) DRG relative weight in the 34 incorrect coding of secondary diagnosis records and 86 missing secondary diagnosis records were 1.20+/-0.79 and 0.78+/-0.64, respectively. The DRG relative weight presented a significant difference resulting from complete and accurate documentation in the medical record, 0.86+/-0.64 (decrease) and 1.09+/- 0.77 (increase) with respect to incorrect coding of secondary diagnosis records and missing secondary diagnosis records (each p<0.001). Among 75 questionnaire respondents, 68 % of physicians and nursing specialists were aware that the principal diagnosis is defined as the condition to be chiefly responsible for occasioning the admission while 18.7 % recognized the principal diagnosis is defined as the most severe condition during the episode of care. Conclusions: The results showed that incorrect coding of secondary diagnosis relating to medical document insufficiency may lead to a decrease in DRG relative weight under the same clinical scenario. The healthcare organization should focus on ensuring accuracy and completeness in clinical documentation.
