临床医师诊断书写不规范对编码准确性的影响OA

Objective To analyze the common non-standard practices in clinical diagnosis documentation and evaluate their specific impact on the accuracy of subsequent International Classification of Diseases(ICD)coding.Methods A retro-spective study was conducted,randomly selecting 800 discharge medical records from February 2024 to November 2025 in our hospital.Based on diagnostic documentation standards,senior coders and clinical experts jointly reviewed and identified non-standard issues in the physicians' diagnostic writing documentation.Subsequently,the initial coding was compared with the gold standard coding based on complete and standardized medical record documentation,and the coding accuracy rate was calculated.The association between non-standard types and coding deviations was analyzed,and the impact on DRG/DIP grouping was simu-lated.Results Among the 800 randomly selected discharge medical records,the proportion of cases with at least one non-stand-ard diagnostic documentation issue was 39.00％(312/800).The most common issue was the omission of key information(187 cases,accounting for 23.38％),followed by non-standard diagnosis terminology(145 cases,accounting for 18.13％).Among the 312 non-standard documentation,the proportion of key information omission was the highest(59.94％).Using the'gold standard'coding determined by the expert group as the reference,the overall initial coding accuracy rate of the 800 cases was 71.25％(570/800).The accuracy rate of the main diagnosis coding was 85.00％(680/800),while the accuracy rate of other diagnoses was relatively lower,at 69.38％(555/800).In the coding deviation group(230 cases),the proportion of cases with key information omission(65.22％)was significantly higher than that in the coding correct group(570 cases,31.58％)(P＜0.05).Chi-square test showed that all types of non-standard diagnostic writing were significantly associated with coding devia-tions(P＜0.001),with the association strength of key information omission being the greatest(OR=21.45,95％CI:14.36-32.06).DRG/DIP simulation analysis indicated that initial coding deviations resulted in changes in grouping outcomes in 46.02％(81/176)of cases,and the corrected case mix index(CMI)decreased from 1.05 to 1.02,causing a potential devia-tion of approximately-2.17％in the total medical payment amount.Conclusion Documentation problems not only directly af-feet the accuracy of coding but also are transmitted through the DRG/DIP grouping system,causing systematic deviations in case-mix classification,resource assessment,and medical payment.This reveals a disconnect between the current quality of internal medical record documents in hospitals and the requirements of external refined healthcare payment reform.Therefore,improving the standardization of clinical diagnosis documentation and establishing a linked mechanism for coding quality control and feed-back is a necessary foundation for ensuring the authenticity and reliability of medical record data and promoting the smooth imple-mentation of medical payment reform.