目的：分析骨科手术患者病案首页中诊断和编码的常见问题，明确专科个性化的改进措施，以提高DRGs入组的准确性。方法：随机抽取某院骨科2019年1-12月手术患者出院病案708份，回顾性分析诊断及编码的主要问题，与临床达成共识后改进，对比两次入组DRGs相关指标的变化。结果：708份骨科手术患者病案首页主要问题集中在：诊断表述不具体76例，主要手术选择错误49例，手术编码遗漏32例，编码选择错误19例，QY病例13例，对存在的问题进行改进后，入组率明显提升，DRGs组数、CMI 、总权重均有不同程度的增加。结论：骨科手术患者病案首页影响DRGs入组的关键点为主要诊断和主要手术，临床医生需准确填写诊断和手术名称，掌握主要诊断和手术选择原则，编码人员需加强专科易错点的审核，首页数据应有效映射临床诊疗实际，才能准确入组。

Objective：To analyze the common problems of diagnosis and coding in the first page of medical records of patients discharged from orthopedic surgery，andto improve the accuracy of DRGs into the group. Methods：Randomly select 708 medical records of surgical patients from January to December 2019 in an orthopedic ward of a hospital. The main problems of diagnosis and coding in the first page of the medical records were retrospectively analyzed，which were improved after reaching a consensus with the clinic，and the changes of DRGs-related indicators in the twice enrolled patients were compared. Results：708 medical record home page main problems focus on：76 cases description is not concrete，selection of surgical errors in 49 cases，surgery coding missed in 32 cases，code selection error in 19 cases，QY in 13 cases，make improvements to existing problems，the rate of group improved significantly，DRG groups，CMI，total weight all have varying degrees of increase. Conclusion：The main diagnosis and main surgery are the key points that affect of DRGs in to the group for the first page of the medical record of orthopedic surgery patients，clinical doctors should accurately fill in the diagnosis and operation names，and master the main principles of diagnosis and surgical choice，coders need to strengthen the audit of specialist error-prone point，the home page data should be effective mapping actual clinical diagnosis and treatment，can accurately into DRG groups.