[Medical records, DRG and intensive care patients]

In order to control the quality of the medical report after a hospital stay with regards to the stay in the intensive care unit (ICU), and to cheque for correct DRG grouping, this study of 428 patients treated in our ICU in 2003 was conducted.

All ICU patients from 2003 were found in our database, which includes specific ICD-10 diagnosis and specific ICU procedures. The medical record summarising the hospital stay (epicrisis) was retrieved for each patient from the hospital's electronic patient files and controlled for correct information regarding the ICU stay. DRG groups for each patient were retrieved from the hospital's administrative database. All stays were re-coded, with all information about the ICU stay was also included. The new DRG codes were compared with the old ones, and the difference in DRG points computed.

The description of the stay in the ICU was missing or very insufficient in 46% of the records. In the DRG control we found that an additional 347.37 DRG points (18.4% of the original sum of all DRG points) were missing, corresponding to a loss to the hospital of 6.2 million NOK. In addition we discovered missing codes for tracheostomy corresponding to 2.8 million NOK, giving a total loss of 9 million NOK.

This study confirms that an adequate description of the stay in the ICU is insufficient in a large number of medical records. This also leads to incorrect DRG grouping of many patients and significant financial losses to the hospital.