摘要
目的分析住院病案首页主要诊断及编码存在的问题,提高病案编码质量。方法根据原国家卫生计生委发布的文件关于病案首页数据填写质量规范(暂行)(2016版),由编码员、编码质控员和各科室病案质控员共同核查某院2018年1月1日-6月30日住院病案首页主要诊断及编码9733份,将核对后的缺陷情况进行统计分析。结果9733份病案存在主要诊断及编码缺陷的有87份,缺陷率为0.89%。前5位缺陷率由高到低的科室依次为ICU、肝胆胰外科、产科、神经外科、心血管内科。缺陷原因分别为主要诊断选择过于笼统占29.89%,能使用联合编码时没使用联合编码占24.14%,O编码错误使用占10.34%,手术并发症的主要诊断选择错误占4.6%,其他各种缺陷合计31.03%。结论住院病案首页主要诊断及编码质量不容乐观,医院应加强临床医师尤其是外科医师的培训、提高编码员业务水平、进行有效的双沟通,提高主要诊断及编码的准确率,提高住院病案首页的质量,为DRGs和三级公立医院绩效考核提供真实可靠的数据。
Objectives To analyze the problems of main diagnosis and coding in the front page of hospital medical record and improve the record codi ng qual ity.Methods Accordi ng to the data of the front page of the hospital medical record issued by the National Health and Family Planning Commssion,the quality standard(provisional version 2016)was filled out 9733 medical records from January 1 st,2018 toj une 30 th,2018 were verified the mai n diagnosis and coding of the front page of medical records by coders,code quality controller and medical records quality controller of each department,and the errors after verification were statistically analyzed.R esults T here were87 main diagnosis and coding errors,and the error rate was 0.89%.The departments with high to low defect rate were ICU,hepatobiliary and pancreatic surgery,obstetrics,neurosurgery,and cardiovascular medicine.The reasons for the defects were that the main diagnostic general choice accounted for 29.89%,the failure to use the combined encoding accounted for 24.14%,the wrong use of O encoding accounted for 10.34%,the main diagnostic error of surgical complications accounted for 4.6%,and other reasons accounted for 31.03%.Conclusions The quality of the front page of hospital medical records was not optimistic.The hospital should strengthen the training of clinicians especially surgeons,inmprove the professional level of coders,and carry out effective double communication to improve the accuracy of the main diagnosis and coding and the quality of the front page of medical records.
作者
陈红菊
Chen Hongju(Department of Medical Records,Tianyou Hospital Affiliated to Wuhan University of Science and Technology,Wuhan 430000,Hubei Province,China)
出处
《中国病案》
2020年第9期10-13,共4页
Chinese Medical Record
关键词
主要诊断
住院病案首页
国际疾病分类
Main diagnosis
Front page of hospital medical records
International classification of diseases
