北京地区16个病种的疾病与手术分类质量评估  

Evaluation of classification quality of diseases and surgeries by coding for 16 diseases in Beijing

作　　者：刘爱民[1] 周晓鸽[1] 秦安京[2] 王文达[3] 达汉玲[4] 李斌[5] 赵青[1] 张丽[6] 

机构地区：[1]北京协和医院,100730 [2]首都医科大学附属北京复兴医院 [3]首都医科大学附属北京友谊医院 [4]煤炭总医院 [5]首都医科大学附属北京朝阳医院 [6]首都医科大学宣武医院

出　　处：《中华医院管理杂志》2008年第3期148-150,147,共4页Chinese Journal of Hospital Administration

基　　金：本课题为首都医学科学发展基金资助课题（2005-1033）

摘　　要：目的评估疾病分类与手术分类的编码质量，为按病种付费的DRGs研究提供依据。方法从北京市23所医院2003年至2004年16个病种的病案及计算机数据库中，各医院抽样100册，要求各医院填写病案摘录卡，由编码专家组对出现的问题进行讲解与培训。在此基础上，医院重新填写病案摘录卡，专家组再抽样5％共9730册病案进行审查。结果100册病案的抽样显示，错误率在50％以上；经培训后的5％的抽样显示，主要疾病诊断错误率为2．01％，全部疾病诊断的错误率为17．04％，主要手术操作的错误率为2．49％，总错误率为22．74％。结论DRGs研究必须重视基础数据质量，而病案摘录卡可作为DRGs研究的重要手段。要加强培训，尽量减少错误编码。Objective To evaluate the classification quality of diseases and surgeries by coding and to provide basis for the study of DRGs-based payment system. Methods The data of 16 diseases were collected from the medical records and computer database of discharged patients of 23 hospitals in Beijing during 2003-2004. One hundred medical records were sampled from each hospital, and the extract cards of medical records were asked to fill in by each hospital. Then the extract cards were reviewed by expert group and the found mistakes on coding were explained. On the basis of training, the extract cards of medical records were refilled and 5% of the study cases, 9 730 records, were sampled for review. Results An error rate of over 50% was found in the coding for 100 medical records from each hospital. For the 5 % random samples following training, the error rate of the principle diagnoses was 2.01%, total error rate for all diagnoses was 17.04%, error rate of principle procedures was 2. 49%, and total error rate of diseases and procedures was 22. 74%. Conclusion In DRGs study, importance should be attached to the quality of basic data, and extract card of medical record can be used as an important means. Training must be strengthened to minimize the error rate of coding.

关 键 词：疾病分类 编码 质量 错误率 

分 类 号：R197.3[医药卫生—卫生事业管理] R512.91[医药卫生—公共卫生与预防医学]