CN117522348A - Method and system for generating medical insurance settlement list of hospitalization medical record (DRG) - Google Patents

Method and system for generating medical insurance settlement list of hospitalization medical record (DRG) Download PDF

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CN117522348A
CN117522348A CN202311767457.0A CN202311767457A CN117522348A CN 117522348 A CN117522348 A CN 117522348A CN 202311767457 A CN202311767457 A CN 202311767457A CN 117522348 A CN117522348 A CN 117522348A
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list
medical
medical records
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丁天宇
黄伟
谢冠超
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Unisound Intelligent Technology Co Ltd
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Abstract

A method and a system for generating a medical insurance settlement list of a medical record DRG in hospitalization are provided, wherein the method searches for the names of diagnosis items which are lack in a medical record first page diagnosis list in an admission diagnosis list and an discharge diagnosis list, and obtains the codes of the diagnosis items corresponding to the names of the diagnosis items through the names of the lack diagnosis items and places the codes into the medical record first page diagnosis list; searching the operation names in the operation record document, searching the operation names which are missing in the operation list of the first page of the medical records, acquiring operation codes corresponding to the missing operation names, and putting the operation codes into the operation list of the first page of the medical records; performing DRGs group-entering analysis on the medical records front page diagnosis list and the medical records front page operation list to obtain a DRGs group-entering result; and generating a medical insurance settlement list according to the DRGs group entering result, the diagnosis cost information obtained from the medical records first page diagnosis list and the operation cost information obtained from the medical records first page operation list. The invention can reduce the workload of the input staff; and the accuracy and the generation efficiency of the medical insurance settlement list are improved.

Description

Method and system for generating medical insurance settlement list of hospitalization medical record (DRG)
Technical Field
The invention relates to the technical field of medical insurance data processing, in particular to a method and a system for generating a DRG medical insurance settlement list of hospitalized medical records.
Background
Disease diagnosis related group (Diagnosis Related Groups, DRG) is an important tool for measuring the quality of service efficiency of medical services and making medical insurance payments. DRG payment is an important means for realizing win-win and promotion of classified diagnosis and treatment and promotion of service mode transition of three parties of medical science, protection and suffering. DRG is essentially a case-combination classification scheme, i.e., a system that manages patients into several diagnostic groups based on age, disease diagnosis, complications, treatment regimen, severity of the condition, and outcome and resource consumption.
At present, after the writing of hospital hospitalization medical records of patients is completed, DRG grouping results are required to be manually input, and medical insurance settlement lists are manually input, so that heavy workload is brought to an input person, and meanwhile, the accuracy of data input is low, and the data input efficiency is low. In conclusion, how to realize efficient and accurate medical insurance settlement list generation has practical application significance.
Disclosure of Invention
Therefore, the invention provides a method and a system for generating a medical insurance settlement list of an hospitalized medical record (DRG), which solve the problems of low efficiency and poor accuracy of the traditional manual data entry.
In order to achieve the above object, the present invention provides the following technical solutions: a method for generating a medical insurance settlement list of hospitalization medical records (DRG) includes:
acquiring a medical records first page diagnosis list, an admission diagnosis list, an discharge diagnosis list and a medical records first page operation list in an electronic medical record document;
searching for the missing diagnosis item names in the medical records top page diagnosis list in the hospital admission diagnosis list and the hospital discharge diagnosis list, acquiring diagnosis item codes corresponding to the diagnosis item names through the missing diagnosis item names, and placing the missing diagnosis item codes of the diagnosis item names into the medical records top page diagnosis list;
searching the operation names in the operation record document, searching the operation names which are missing in the operation list of the first page of the medical records, acquiring operation codes corresponding to the missing operation names through the missing operation names, and placing the operation codes corresponding to the missing operation names into the operation list of the first page of the medical records;
performing DRGs group entering analysis on the medical records front page diagnosis list and the medical records front page operation list to obtain a DRGs group entering result, wherein the DRGs group entering result comprises a group entering name, a payment standard, weight and a profit and loss amount;
and generating a medical insurance settlement list according to the DRGs group entering result, the diagnosis cost information acquired from the medical records first page diagnosis list and the operation cost information acquired from the medical records first page operation list.
As a preferred scheme of the medical insurance settlement list generation method of the hospitalization medical record (DRG), the obtained diagnosis item codes corresponding to the diagnosis item names are subjected to matching verification by adopting the diagnosis names and the coding models, and the diagnosis item codes of the diagnosis item names after the matching verification are placed in the medical records front page diagnosis list.
As a preferred scheme of the medical insurance settlement list generation method of the hospitalization medical record (DRG), the operation codes corresponding to the obtained missing operation names are matched and checked by adopting the operation names and the code model, and the operation codes corresponding to the operation names after the matching and checking are put into the medical records first page operation list.
As a preferred scheme of the hospitalized medical record DRG medical insurance settlement list generation method, the method further comprises the following steps: constructing a mapping relation between a clinical version medical insurance code and a medical insurance code, and acquiring a medical insurance diagnosis name, a diagnosis code, a surgery name and a surgery code of a designated diagnosis or surgery project through the clinical version medical insurance code of the designated diagnosis or surgery project;
and converting the medical records front page diagnosis list and the medical records front page operation list of the clinical edition into the medical records front page diagnosis list and the medical records front page operation list of the medical records front page according to the acquired medical records front page diagnosis name, diagnosis code, operation name and operation code of the appointed diagnosis or operation item.
As a preferred scheme of the hospitalized medical record DRG medical insurance settlement list generation method, the method further comprises the following steps: and analyzing the profit and loss amount in the DRGs grouping result, filtering the grouping items with the profit and loss amount which is 2 times greater than the total cost, and selecting the largest profit and loss amount record from the rest grouping result.
The invention also provides a system for generating the medical insurance settlement list of the hospitalized medical record DRG, which comprises the following steps:
the list acquisition module is used for acquiring a medical records first page diagnosis list, an admission diagnosis list, an discharge diagnosis list and a medical records first page operation list in the electronic medical record document;
the diagnosis list checking module is used for searching the diagnosis item names which are missing in the medical records top page diagnosis list in the hospital admission diagnosis list and the hospital discharge diagnosis list, acquiring diagnosis item codes corresponding to the diagnosis item names through the missing diagnosis item names, and placing the diagnosis item codes of the missing diagnosis item names into the medical records top page diagnosis list;
the operation list checking module is used for searching operation names in the operation record file, searching operation names which are missing in the operation list of the first page of the medical records, acquiring operation codes corresponding to the missing operation names through the missing operation names, and placing the operation codes corresponding to the missing operation names into the operation list of the first page of the medical records;
the DRGs group entering module is used for carrying out DRGs group entering analysis on the medical records first page diagnosis list and the medical records first page operation list to obtain a DRGs group entering result, wherein the DRGs group entering result comprises a group entering name, a payment standard, a weight and a profit and loss amount;
and the medical insurance settlement list generation module is used for generating a medical insurance settlement list according to the DRGs grouping result, the diagnosis cost information acquired from the medical records homepage diagnosis list and the operation cost information acquired from the medical records homepage operation list.
And as a preferred scheme of the medical insurance settlement list generation system of the hospitalization medical record (DRG), the diagnosis list checking module performs matching check on the diagnosis item codes corresponding to the obtained diagnosis item names by adopting the diagnosis names and the coding model, and places the diagnosis item codes of the diagnosis item names after the matching check into the medical records front page diagnosis list.
And as a preferred scheme of the medical insurance settlement list generation system of the hospitalization medical record (DRG), the operation list checking module performs matching check on the operation codes corresponding to the obtained lacking operation names by adopting the operation names and the code model, and places the operation codes corresponding to the operation names after the matching check into the medical records home page operation list.
As a preferred scheme of the hospitalized medical record DRG medical insurance settlement list generation system, the system further comprises:
the mapping relation construction module is used for constructing a mapping relation between the clinical version medical insurance code and the medical insurance code, and acquiring a medical insurance diagnosis name, a diagnosis code, a surgery name and a surgery code of a designated diagnosis or surgery item through the clinical version medical insurance code of the designated diagnosis or surgery item;
and the version conversion module is used for converting the medical records front page diagnosis list and the medical records front page operation list of the clinical version into the medical records front page diagnosis list and the medical records front page operation list of the medical records front page according to the acquired medical records front page diagnosis name, diagnosis code, operation name and operation code of the appointed diagnosis or operation project.
And as a preferred scheme of the medical insurance settlement list generation system of the hospitalization medical records (DRG), analyzing the amount of the surplus and the deficit in the DRGs grouping result in the DRGs grouping module, filtering out grouping items with the surplus and deficit amount exceeding 2 times of the total cost, and selecting the largest surplus and deficit amount record in the rest grouping result.
The invention has the following advantages: acquiring a medical records first page diagnosis list, an admission diagnosis list, an discharge diagnosis list and a medical records first page operation list in an electronic medical record document; searching for the missing diagnosis item names in the medical records top page diagnosis list in the hospital admission diagnosis list and the hospital discharge diagnosis list, acquiring diagnosis item codes corresponding to the diagnosis item names through the missing diagnosis item names, and placing the missing diagnosis item codes of the diagnosis item names into the medical records top page diagnosis list; searching the operation names in the operation record document, searching the operation names which are missing in the operation list of the first page of the medical records, acquiring operation codes corresponding to the missing operation names through the missing operation names, and placing the operation codes corresponding to the missing operation names into the operation list of the first page of the medical records; performing DRGs group entering analysis on the medical records front page diagnosis list and the medical records front page operation list to obtain a DRGs group entering result, wherein the DRGs group entering result comprises a group entering name, a payment standard, weight and a profit and loss amount; and generating a medical insurance settlement list according to the DRGs group entering result, the diagnosis cost information acquired from the medical records first page diagnosis list and the operation cost information acquired from the medical records first page operation list. The invention can greatly lighten the workload of the input staff; and the data accuracy of the medical insurance settlement list is improved, and the generation efficiency of the medical insurance settlement list is improved.
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In order to more clearly illustrate the embodiments of the present invention or the technical solutions in the prior art, the drawings used in the description of the embodiments or the prior art will be briefly described below. It will be apparent to those skilled in the art from this disclosure that the drawings described below are merely exemplary and that other embodiments may be derived from the drawings provided without undue effort.
The structures, proportions, sizes, etc. shown in the present specification are shown only for the purposes of illustration and description, and are not intended to limit the scope of the invention, which is defined by the claims, so that any structural modifications, changes in proportions, or adjustments of sizes, which do not affect the efficacy or the achievement of the present invention, should fall within the scope of the invention.
Fig. 1 is a flow chart of a method for generating a medical insurance settlement list for hospitalization medical records DRG provided in embodiment 1 of the present invention;
fig. 2 is a technical route schematic diagram of a method for generating a medical insurance settlement list for hospitalization medical records DRG provided in embodiment 1 of the present invention;
fig. 3 is a practical interface of the method for generating the medical insurance statement of medical records DRG provided in embodiment 1 of the present invention;
fig. 4 is a schematic diagram of a system architecture for generating a medical insurance statement of medical records DRG provided in embodiment 2 of the present invention.
Detailed Description
Other advantages and advantages of the present invention will become apparent to those skilled in the art from the following detailed description, which, by way of illustration, is to be read in connection with certain specific embodiments, but not all embodiments. All other embodiments, which can be made by those skilled in the art based on the embodiments of the invention without making any inventive effort, are intended to be within the scope of the invention.
Example 1
Referring to fig. 1 and 2, embodiment 1 of the present invention provides a method for generating a medical insurance settlement list for hospitalized medical records DRG, which includes the following steps:
s1, acquiring a medical records first page diagnosis list, an admission diagnosis list, an discharge diagnosis list and a medical records first page operation list in an electronic medical record document;
s2, searching for the missing diagnosis item names in the medical records top page diagnosis list in the admission diagnosis list and the discharge diagnosis list, acquiring diagnosis item codes corresponding to the diagnosis item names through the missing diagnosis item names, and placing the missing diagnosis item codes of the diagnosis item names into the medical records top page diagnosis list;
s3, searching the operation names in the operation record file, searching the operation names which are missing in the operation list of the first page of the medical records, acquiring operation codes corresponding to the missing operation names through the missing operation names, and placing the operation codes corresponding to the missing operation names in the operation list of the first page of the medical records;
s4, carrying out DRGs group entering analysis on the medical records front page diagnosis list and the medical records front page operation list to obtain a DRGs group entering result, wherein the DRGs group entering result comprises a group entering name, a payment standard, a weight and a profit and loss amount;
s5, generating a medical insurance settlement list according to the DRGs grouping result, the diagnosis cost information acquired from the medical records first page diagnosis list and the operation cost information acquired from the medical records first page operation list.
In this embodiment, based on the medical records top page diagnosis list, the diagnosis item names which do not exist in the medical records top page diagnosis list are searched in the admission diagnosis list and the discharge diagnosis list, and the diagnosis codes are obtained through the diagnosis item names and then placed in the medical records top page diagnosis list. And based on the medical records first page operation list, searching operation records which do not exist in the medical records first page operation list in the operation names of the operation record files of the patient, acquiring operation codes through the operation names, and placing the operation codes in the medical records first page operation list.
In this embodiment, matching verification is performed on the obtained diagnosis item code corresponding to the diagnosis item name by using a diagnosis name and a coding model, and the diagnosis item code of the diagnosis item name after matching verification is put into the medical records home page diagnosis list; and carrying out matching verification on the obtained surgical codes corresponding to the missing surgical names by adopting the surgical names and the coding model, and placing the surgical codes corresponding to the surgical names after the matching verification into the surgical list of the medical records first page.
Specifically, the diagnosis item name with the highest matching degree is obtained through a pre-trained diagnosis name and code model, whether the diagnosis item code is correct or not is checked, the diagnosis name and code with the highest matching degree is obtained through the diagnosis name and code model and is placed in a medical records top page diagnosis list, and the diagnosis list for admission and discharge is not filled in the medical records top page diagnosis list. And acquiring the surgical name and code with the highest matching degree from the surgical record names which do not exist in the surgical list of the first medical record in the surgical document through the surgical name and code model, and putting the surgical name and code into the surgical list of the first medical record.
The diagnosis name and coding model is constructed according to a diagnosis name and coding library (ICD-11 dictionary library), the ICD-11 dictionary library is an international disease classification, and diseases are classified according to rules and expressed by a coding method according to the characteristics of the diseases. The surgical name and coding model are constructed according to ICD-9-CM-3.
In this embodiment, the method further includes: constructing a mapping relation between a clinical version medical insurance code and a medical insurance code, and acquiring a medical insurance diagnosis name, a diagnosis code, a surgery name and a surgery code of a designated diagnosis or surgery project through the clinical version medical insurance code of the designated diagnosis or surgery project; and converting the medical records front page diagnosis list and the medical records front page operation list of the clinical edition into the medical records front page diagnosis list and the medical records front page operation list of the medical records front page according to the acquired medical records front page diagnosis name, diagnosis code, operation name and operation code of the appointed diagnosis or operation item.
Wherein, the clinical version of medical insurance code is the classification and coding of clinical diagnosis and operation by a national clinical diagnosis and operation classification (CCDO) system. The medical insurance code refers to a medical insurance payment standard (MBS) system, which is a payment standard formulated according to medical insurance policies and is used for determining reimbursement amounts of various medical services. The medical insurance settlement list data accuracy is improved by converting the medical records first page diagnosis list and the medical records first page operation list of the clinical edition into the medical records first page diagnosis list and the medical records first page operation list of the medical insurance edition.
In this embodiment, the method further includes: and analyzing the profit and loss amount in the DRGs grouping result, filtering the grouping items with the profit and loss amount which is 2 times greater than the total cost, and selecting the largest profit and loss amount record from the rest grouping result.
Referring to fig. 3, in particular, by combining all diagnosis lists and operation lists, main diagnosis, other diagnosis, main operation, other operation, and group results are obtained through DRGs group entry analysis, and the DRGs group entry results include group entry names, payment criteria, weights, and profit and loss amounts. Filtering the information that the total cost is 2 times greater than the sum of the information, selecting the record with the maximum sum of the information from the rest group entering results, and automatically filling the medical records first page diagnosis list and the medical records first page operation list into a settlement list; the expense information is acquired from the medical records top page, so that a complete medical insurance settlement list is generated. Meanwhile, the correctness of the medical insurance settlement list diagnosis list and the operation list can be manually checked.
In summary, the medical records of the electronic medical record file are obtained through the medical records first page diagnosis list, the admission diagnosis list, the discharge diagnosis list and the medical records first page operation list; searching for the missing diagnosis item names in the medical records top page diagnosis list in the hospital admission diagnosis list and the hospital discharge diagnosis list, acquiring diagnosis item codes corresponding to the diagnosis item names through the missing diagnosis item names, and placing the missing diagnosis item codes of the diagnosis item names into the medical records top page diagnosis list; searching the operation names in the operation record document, searching the operation names which are missing in the operation list of the first page of the medical records, acquiring operation codes corresponding to the missing operation names through the missing operation names, and placing the operation codes corresponding to the missing operation names into the operation list of the first page of the medical records; performing DRGs group entering analysis on the medical records front page diagnosis list and the medical records front page operation list to obtain a DRGs group entering result, wherein the DRGs group entering result comprises a group entering name, a payment standard, weight and a profit and loss amount; and generating a medical insurance settlement list according to the DRGs group entering result, the diagnosis cost information acquired from the medical records first page diagnosis list and the operation cost information acquired from the medical records first page operation list. The invention can greatly lighten the workload of the input staff; and the data accuracy of the medical insurance settlement list is improved, and the generation efficiency of the medical insurance settlement list is improved.
It should be noted that the method of the embodiments of the present disclosure may be performed by a single device, such as a computer or a server. The method of the embodiment can also be applied to a distributed scene, and is completed by mutually matching a plurality of devices. In the case of such a distributed scenario, one of the devices may perform only one or more steps of the methods of embodiments of the present disclosure, the devices interacting with each other to accomplish the methods.
It should be noted that the foregoing describes some embodiments of the present disclosure. Other embodiments are within the scope of the following claims. In some cases, the actions or steps recited in the claims may be performed in a different order than in the embodiments described above and still achieve desirable results. In addition, the processes depicted in the accompanying figures do not necessarily require the particular order shown, or sequential order, to achieve desirable results. In some embodiments, multitasking and parallel processing are also possible or may be advantageous.
Example 2
Referring to fig. 4, embodiment 2 of the present invention further provides a system for generating a medical insurance settlement list for hospitalized medical records DRG, including:
the list acquisition module 1 is used for acquiring a medical records first page diagnosis list, an admission diagnosis list, an discharge diagnosis list and a medical records first page operation list in the electronic medical record document;
a diagnosis list checking module 2, configured to search the diagnosis list for the missing diagnosis item names in the medical records top page diagnosis list and the discharge diagnosis list, obtain diagnosis item codes corresponding to the diagnosis item names through the missing diagnosis item names, and put the missing diagnosis item codes of the diagnosis item names into the medical records top page diagnosis list;
the operation list checking module 3 is used for searching operation names in the operation record file, searching operation names which are missing in the operation list of the first page of the medical records, acquiring operation codes corresponding to the missing operation names through the missing operation names, and placing the operation codes corresponding to the missing operation names into the operation list of the first page of the medical records;
the DRGs group entering module 4 is configured to perform DRGs group entering analysis on the medical records first page diagnosis list and the medical records first page operation list to obtain a DRGs group entering result, where the DRGs group entering result includes a group entering name, a payment standard, a weight and a profit and loss amount;
and the medical insurance settlement list generation module 5 is used for generating a medical insurance settlement list according to the DRGs grouping result, the diagnosis cost information acquired from the medical records homepage diagnosis list and the operation cost information acquired from the medical records homepage operation list.
In this embodiment, the diagnosis list checking module 2 performs matching check on the obtained diagnosis item code corresponding to the diagnosis item name by using a diagnosis name and a code model, and places the diagnosis item code of the diagnosis item name after matching check in the medical records top page diagnosis list.
In this embodiment, in the operation list checking module 2, the operation codes corresponding to the obtained missing operation names are matched and checked by using the operation names and the code model, and the operation codes corresponding to the operation names after the matching and checking are put into the operation list of the medical records.
In this embodiment, the method further includes:
the mapping relation construction module 6 is used for constructing a mapping relation between the clinical version medical insurance code and the medical insurance code, and acquiring the medical insurance diagnosis name, the diagnosis code, the operation name and the operation code of the appointed diagnosis or operation item through the clinical version medical insurance code of the appointed diagnosis or operation item;
and the version conversion module 7 is used for converting the medical records front page diagnosis list and the medical records front page operation list of the clinical version into the medical records front page diagnosis list and the medical records front page operation list of the medical records front page according to the acquired medical records front page diagnosis name, diagnosis code, operation name and operation code of the designated diagnosis or operation item.
In this embodiment, the DRGs grouping module 4 analyzes the amount of the profit and the loss in the DRGs grouping result, filters the grouping items with the amount of the profit and the loss exceeding 2 times of the total cost, and selects the largest record of the profit and the loss in the remaining grouping result.
It should be noted that, because the content of information interaction and execution process between the modules of the above system is based on the same concept as the method embodiment in embodiment 1 of the present application, the technical effects brought by the content are the same as the method embodiment of the present application, and specific content can be referred to the description in the foregoing method embodiment shown in the present application, which is not repeated here.
Example 3
Embodiment 3 of the present invention provides a non-transitory computer readable storage medium having stored therein program code for a method for generating a medical record DRG medical insurance statement of settlement of an inpatient medical record, the program code including instructions for executing the method for generating a medical record DRG medical insurance statement of settlement of an inpatient medical record of embodiment 1 or any possible implementation thereof.
Computer readable storage media can be any available media that can be accessed by a computer or data storage devices, such as servers, data centers, etc., that contain an integration of one or more available media. The usable medium may be a magnetic medium (e.g., a floppy Disk, hard Disk, magnetic tape), an optical medium (e.g., DVD), or a semiconductor medium (e.g., solid State Disk, SSD), etc.
Example 4
Embodiment 4 of the present invention provides an electronic device, including: a memory and a processor;
the processor and the memory complete communication with each other through a bus; the memory stores program instructions executable by the processor that invoke the program instructions to perform the hospitalized medical record DRG medical insurance statement generation method of embodiment 1 or any possible implementation thereof.
Specifically, the processor may be implemented by hardware or software, and when implemented by hardware, the processor may be a logic circuit, an integrated circuit, or the like; when implemented in software, the processor may be a general-purpose processor, implemented by reading software code stored in a memory, which may be integrated in the processor, or may reside outside the processor, and which may reside separately.
In the above embodiments, it may be implemented in whole or in part by software, hardware, firmware, or any combination thereof. When implemented in software, may be implemented in whole or in part in the form of a computer program product. The computer program product includes one or more computer instructions. When loaded and executed on a computer, produces a flow or function in accordance with embodiments of the present invention, in whole or in part. The computer may be a general purpose computer, a special purpose computer, a computer network, or other programmable apparatus. The computer instructions may be stored in or transmitted from one computer-readable storage medium to another, for example, by wired (e.g., coaxial cable, optical fiber, digital Subscriber Line (DSL)), or wireless (e.g., infrared, wireless, microwave, etc.).
It will be appreciated by those skilled in the art that the modules or steps of the invention described above may be implemented in a general purpose computing device, they may be concentrated on a single computing device, or distributed across a network of computing devices, they may alternatively be implemented in program code executable by computing devices, so that they may be stored in a memory device for execution by computing devices, and in some cases, the steps shown or described may be performed in a different order than that shown or described, or they may be separately fabricated into individual integrated circuit modules, or multiple modules or steps within them may be fabricated into a single integrated circuit module for implementation. Thus, the present invention is not limited to any specific combination of hardware and software.
While the invention has been described in detail in the foregoing general description and specific examples, it will be apparent to those skilled in the art that modifications and improvements can be made thereto. Accordingly, such modifications or improvements may be made without departing from the spirit of the invention and are intended to be within the scope of the invention as claimed.

Claims (10)

1. A method for generating a medical insurance settlement list of a hospitalized medical record (DRG) is characterized by comprising the following steps:
acquiring a medical records first page diagnosis list, an admission diagnosis list, an discharge diagnosis list and a medical records first page operation list in an electronic medical record document;
searching for the missing diagnosis item names in the medical records top page diagnosis list in the hospital admission diagnosis list and the hospital discharge diagnosis list, acquiring diagnosis item codes corresponding to the diagnosis item names through the missing diagnosis item names, and placing the missing diagnosis item codes of the diagnosis item names into the medical records top page diagnosis list;
searching the operation names in the operation record document, searching the operation names which are missing in the operation list of the first page of the medical records, acquiring operation codes corresponding to the missing operation names through the missing operation names, and placing the operation codes corresponding to the missing operation names into the operation list of the first page of the medical records;
performing DRGs group entering analysis on the medical records front page diagnosis list and the medical records front page operation list to obtain a DRGs group entering result, wherein the DRGs group entering result comprises a group entering name, a payment standard, weight and a profit and loss amount;
and generating a medical insurance settlement list according to the DRGs group entering result, the diagnosis cost information acquired from the medical records first page diagnosis list and the operation cost information acquired from the medical records first page operation list.
2. The method for generating a medical insurance settlement list for hospitalization medical records DRG according to claim 1, wherein the obtained diagnosis item codes corresponding to the diagnosis item names are subjected to matching verification by adopting a diagnosis name and a coding model, and the diagnosis item codes of the diagnosis item names after matching verification are put into the medical records top page diagnosis list.
3. The method for generating the medical insurance settlement list for the hospitalization medical record DRG according to claim 1, wherein the obtained operation codes corresponding to the lacking operation names are subjected to matching verification by adopting the operation names and the coding model, and the operation codes corresponding to the operation names after the matching verification are placed in the medical record top page operation list.
4. The method for generating a medical insurance statement of settlement of hospitalized medical records DRG according to claim 1, further comprising: constructing a mapping relation between a clinical version medical insurance code and a medical insurance code, and acquiring a medical insurance diagnosis name, a diagnosis code, a surgery name and a surgery code of a designated diagnosis or surgery project through the clinical version medical insurance code of the designated diagnosis or surgery project;
and converting the medical records front page diagnosis list and the medical records front page operation list of the clinical edition into the medical records front page diagnosis list and the medical records front page operation list of the medical records front page according to the acquired medical records front page diagnosis name, diagnosis code, operation name and operation code of the appointed diagnosis or operation item.
5. The method for generating a medical insurance statement of settlement of hospitalized medical records DRG according to claim 1, further comprising: and analyzing the profit and loss amount in the DRGs grouping result, filtering the grouping items with the profit and loss amount which is 2 times greater than the total cost, and selecting the largest profit and loss amount record from the rest grouping result.
6. A system for generating a medical insurance settlement list of hospitalization medical records, comprising:
the list acquisition module is used for acquiring a medical records first page diagnosis list, an admission diagnosis list, an discharge diagnosis list and a medical records first page operation list in the electronic medical record document;
the diagnosis list checking module is used for searching the diagnosis item names which are missing in the medical records top page diagnosis list in the hospital admission diagnosis list and the hospital discharge diagnosis list, acquiring diagnosis item codes corresponding to the diagnosis item names through the missing diagnosis item names, and placing the diagnosis item codes of the missing diagnosis item names into the medical records top page diagnosis list;
the operation list checking module is used for searching operation names in the operation record file, searching operation names which are missing in the operation list of the first page of the medical records, acquiring operation codes corresponding to the missing operation names through the missing operation names, and placing the operation codes corresponding to the missing operation names into the operation list of the first page of the medical records;
the DRGs group entering module is used for carrying out DRGs group entering analysis on the medical records first page diagnosis list and the medical records first page operation list to obtain a DRGs group entering result, wherein the DRGs group entering result comprises a group entering name, a payment standard, a weight and a profit and loss amount;
and the medical insurance settlement list generation module is used for generating a medical insurance settlement list according to the DRGs grouping result, the diagnosis cost information acquired from the medical records homepage diagnosis list and the operation cost information acquired from the medical records homepage operation list.
7. The system for generating a medical insurance settlement list for hospitalization medical records DRG according to claim 6, wherein the diagnosis list checking module performs matching verification on the diagnosis item code corresponding to the obtained diagnosis item name by using a diagnosis name and code model, and places the diagnosis item code of the diagnosis item name after matching verification into the medical records front page diagnosis list.
8. The system for generating a medical insurance statement of medical history DRG according to claim 6, wherein the operation list checking module performs matching checking on the operation code corresponding to the obtained missing operation name by using the operation name and the code model, and places the operation code corresponding to the operation name after matching checking in the medical history top page operation list.
9. The system for generating a medical insurance statement of medical records DRG as defined in claim 6, further comprising:
the mapping relation construction module is used for constructing a mapping relation between the clinical version medical insurance code and the medical insurance code, and acquiring a medical insurance diagnosis name, a diagnosis code, a surgery name and a surgery code of a designated diagnosis or surgery item through the clinical version medical insurance code of the designated diagnosis or surgery item;
and the version conversion module is used for converting the medical records front page diagnosis list and the medical records front page operation list of the clinical version into the medical records front page diagnosis list and the medical records front page operation list of the medical records front page according to the acquired medical records front page diagnosis name, diagnosis code, operation name and operation code of the appointed diagnosis or operation project.
10. The system for generating a medical insurance settlement list for hospitalization medical records according to claim 6, wherein the DRGs grouping module analyzes the amount of the surplus and the deficit in the DRGs grouping result, filters out the grouping items with the surplus and the deficit amount exceeding 2 times of the total cost, and selects the largest of the surplus and the deficit amount records in the remaining grouping result.
CN202311767457.0A 2023-12-20 2023-12-20 Method and system for generating medical insurance settlement list of hospitalization medical record (DRG) Pending CN117522348A (en)

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CN202311767457.0A CN117522348A (en) 2023-12-20 2023-12-20 Method and system for generating medical insurance settlement list of hospitalization medical record (DRG)

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CN202311767457.0A CN117522348A (en) 2023-12-20 2023-12-20 Method and system for generating medical insurance settlement list of hospitalization medical record (DRG)

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CN117522348A true CN117522348A (en) 2024-02-06

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