Die Vidierkonferenz

Autor: M. Schrappe, T. Efe, Dieter Mann, M. Schnabel, M. Schaeg, L. Gotzen, T. v. Garrel
Rok vydání: 2004
Předmět:
Zdroj: Der Chirurg. 75:1013-1020
ISSN: 1433-0385
0009-4722
DOI: 10.1007/s00104-004-0874-0
Popis: INTRODUCTION The introduction of the German Diagnostic Related Groups (D-DRG) system requires redesigning administrative patient management strategies. Wrong coding leads to inaccurate grouping and endangers the reimbursement of treatment costs. This situation emphasizes the roles of documentation and coding as factors of economical success. PURPOSE The aims of this study were to assess the quantity and quality of initial documentation and coding (ICD-10 and OPS-301) and find operative strategies to improve efficiency and strategic means to ensure optimal documentation and coding quality. METHODS In a prospective study, documentation and coding quality were evaluated in a standardized way by weekly assessment. RESULTS Clinical data from 1385 inpatients were processed for initial correctness and quality of documentation and coding. Principal diagnoses were found to be accurate in 82.7% of cases, inexact in 7.1%, and wrong in 10.1%. Effects on financial returns occurred in 16%. Based on these findings, an optimized, interdisciplinary, and multiprofessional workflow on medical documentation, coding, and data control was developed. CONCLUSIONS Workflow incorporating regular assessment of documentation and coding quality is required by the DRG system to ensure efficient accounting of hospital services. Interdisciplinary and multiprofessional cooperation is recognized to be an important factor in establishing an efficient workflow in medical documentation and coding.
Databáze: OpenAIRE
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