Collection! The Home of the death case and the key points of writing the medical record

According to the principles and requirements of the International Classification of Diseases (ICD-10) coding regulations, the correct writing of the main disease diagnosis in the Home of the medical record has always been the focus of the quality monitoring of the medical records of most medical institutions, and the correct filling of the death case affects the data accuracy of multiple negative indicators and the final judgment of the medical dispute, so it is very important to fill in the Home of the death case and the medical record correctly.

Principles for filling in the Home of death cases

According to the national public hospital performance appraisal and medical record writing standards, the requirements for filling in the Home of death medical records are as follows:

1. The Home discharge method of the death case must be filled in 5-death, and the main diagnosis is selected in line with the "three most principles" of the main diagnosis of the medical record Home. (More on this below)

2. Fill in "death" for all diagnoses on the Home of the death medical record

Third, the main diagnosis of the death record Home avoids 115 low-risk diseases as much as possible.

Conditions for determining death in the low-risk group of the national examination: 1. The main diagnosis is in the low-risk disease, 2. The outcome is death

The DRG group with low risk of death is calculated according to the mortality rate of each DRG group in the evaluation area, and with the increase of case data, the mortality rate of each DRG group will change, and the death risk level of some DRG groups will also change accordingly, so the name (diagnosis), proportion, and low-risk death cases of the low-risk group are not fixed, and the data are different for different time periods selected for querying. Therefore, the 115 low-risk diseases released in the Detailed Rules for the Evaluation of Graded Hospitals (2022 Edition) can only provide reference and try to avoid the occurrence of relevant primary diagnoses in death cases, but it does not completely guarantee that the case will not be included in the low-risk death disease group.

The principle of selection of the main diagnosis in the case of death

To correctly select the main diagnosis of death cases, the 2016 edition of the "Hospitalization Home Data Filling and Treatment Specifications" stipulates that "the dying state of the disease cannot be used as the main diagnosis in principle", and the death cases are still selected according to the principle of primary diagnosis selection, that is, the principle of etiology and the principle of "three most". Do not use "circulatory failure", "respiratory failure", "cardiac arrest", "multi-organ failure" end-of-life status as the primary diagnosis.

In the 2021 version of the "Specifications for Filling in the Settlement List of Medical Security Funds", it is stipulated that "when a cancer patient dies in hospitalization, the main diagnosis should be correctly selected according to the specific situation of the hospitalization according to the above requirements".

A summary of common errors in writing death records

1. Home of the medical record

The Home of the case is to concisely summarize the relevant information of the patient during the hospitalization period in a specific table to form a summary of the case data, including the basic information of the patient, the information of the hospitalization process, the diagnosis and treatment information, and the cost information.

Common mistakes:

1. The discharge date is incorrect

This common problem is that the date of discharge does not match the time of death, often in hours or minutes.

The "Quality Specification for Filling in the Data on the Home of Inpatient Medical Records" points out that the discharge time refers to the time when the patient leaves the ward at the end of treatment or termination of treatment, in which the deceased patient refers to the time of his death, and the recording time should be accurate to the minute.

2. The main diagnosis is selected incorrectly

(1) Multiple diseases are used as the primary diagnosis at the same time; Coronary arteriosclerotic heart disease is the main diagnosis of patients with acute myocardial infarction and acute angina;

(2) respiratory and circulatory failure and multi-organ failure were the main diagnoses, while fatal diseases were taken as other diagnoses;

(3) For patients who were hospitalized for surgical treatment, diseases consistent with surgical treatment were not selected as the primary diagnosis.

example

The patient was an 83-year-old male, hospitalized for 16 days, and his death record was mainly diagnosed with multiple organ failure, and the other diagnoses were acute diffuse peritonitis, gastric perforation, septic shock, old cerebral infarction, etc., and the main surgery was gastric ulcer suture.

Analysis: Through reading the medical records, it was found that the patient was hospitalized with gastric ulcer perforation and performed surgery to suture the gastric ulcer site, and multi-organ failure could not be used as the primary diagnosis, so the main diagnosis of this Home should be modified to gastric ulcer with perforation.

3. The autopsy of the deceased patient was omitted

This item is often overlooked, and for deceased patients, it can only be selected yes or no, and cannot be replaced with "-".

4. The number of rescue and success is omitted or wrong

Common mistakes such as hospice care before the patient's death are counted as 1 resuscitation and the number of successes is counted as 0.

The "Basic Standards for Medical Record Writing" requires that "the pre-death rescue of patients with chronic wasting diseases shall not be counted according to the rescue". The patient was rescued twice within 24 h and the rescue was successful, and the number of rescues was counted as 2 times and 2 times were successful. The "Basic Standards for Medical Record Writing" requires that "successful rescue" means that the vital signs return to normal and the condition is stable for more than 24 hours; After rescue, the condition is stable for more than 24 hours, and the critical situation needs to be rescued again, which is calculated according to the second rescue". The correct calculation should be 1 rescue and 1 success.

2. Discharge records

The discharge record refers to the treating physician's summary of the patient's diagnosis and treatment during the hospitalization, which mainly includes the admission situation, admission diagnosis, diagnosis and treatment process, discharge diagnosis, etc.

Common mistakes:

1. There is no main diagnosis and treatment process

The discharge record is a summary of the patient's diagnosis and treatment during the hospitalization by the treating physician and should be completed before the patient is discharged. Among them, the diagnosis and treatment process is an important part of the discharge record.

2. There is no therapeutic effect and disease prognosis

The treating physician should record the patient's treatment effect and disease prognosis before discharge in detail in the "discharge" column of the discharge record, which can be used for the reference of other physicians.

3. Death records

Death records refer to the detailed records of the diagnosis and treatment and rescue process of the patient in charge of treatment during the hospitalization. The content of the record includes the time of admission, the time of death, the status of admission, the diagnosis of admission, the diagnosis and treatment process (especially the changes in the condition and the rescue process), the cause of death and the diagnosis of death, etc., which should be completed within 24 hours after the death of the patient.

Common mistakes:

1. The record of the occurrence and development of the disease is too simple.

example

A patient with ruptured aortic dissection aneurysm and bleeding was recorded in the admission column as "severe pain in the chest, abdomen and back was admitted to the hospital in one day", but the word "chest pain" did not appear in the chief complaint and present medical history in the admission record, indicating that the record was incomplete and defective.

2. The cause of death was not stated

(1) The main causes of death of the patient should be briefly analyzed and recorded in the death record.

(2) The time of death in the death record is not specific, or does not match the doctor's order and the time of the body temperature list. The time of death should be specific to the minute and should coincide with the time of death recorded on the temporary medical order and temperature list.

4. Records of discussion of death cases

The content of the discussion record of the death case is mainly the analysis of the patient's disease diagnosis, disease development and prognosis, focusing on the analysis of the causes and influencing factors of death.

Common mistakes:

1. Case discussion is omitted

In addition to being written in a routine manner, the death record requires objectivity, completeness, science, truthfulness and continuity, and also requires that a death discussion and autopsy must be conducted within a week to clarify the cause of death and summarize lessons learned. Some of the death discussions are mere formalities, and the recorders represent the opinions of the discussants, and the content of the speeches is similar, without careful analysis and summary of lessons learned, and even some are inconsistent with the content of the analysis, and the basis for diagnosis is inconsistent with the results of the examination.

Source: Yiyoushu, Jinchuang Technology (reprinted for sharing only, the copyright belongs to the original author.) If there is an error or infringement of the source, please contact us, we will correct and delete it in time, thank you! ）

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