北京21所医院疾病与手术编码错误原因分析  

An Analysis on the Reasons of the Wrong Codes of Diseases and Operations in 21 Hospitals in Beijing

作　　者：秦安京[1] 王文达[2] 达汉玲[3] 

机构地区：[1]首都医科大学附属复兴医院 [2]首都医科大学附属北京友谊医院 [3]煤炭总医院

出　　处：《中国病案》2008年第7期4-6,共3页Chinese Medical Record

摘　　要：目的分析北京市21家医院2003年全病种病案摘录中疾病与手术编码错误的主要原因,方法抽查了北京市21家医院2003年全病种病案176,800册,抽样5%共8840册病案,对本次检查的病案摘录中出现的疾病与手术编码错误进行统计分析,结果全部有误差的病案1602例,除去主要诊断与手术选择不正确和其他诊断与手术摘录遗漏外其中编码有误差的1014例错误率为抽查病例的11.47%,占总错误的63.29%。结论通过分析疾病与手术编码错误之主要原因,以提高疾病与手术操作编码的准确性。Objective To analyze the main reasons why the codes of diseases and operations are wrong from the extracted full medical records in 21 hospitals in Beijing in 2003. Method We spot-checked 176,800 medical records from 21 hospitals in Beijing in 2003. And 8840 （5 % ） of them are used as samples. And we statistically analyzed the cases with errors in the codes of diseases and operations from the selected samples. Results There are 1602 cases that are with full errors, among them, 1014 cases in which the codes of the main diagnoses and of operations are incorrect, or the extractions of the diagnoses or operations are missed out, -the percentage is 63.29 % of 1602. Conclusion By analyzing the main reasons of the wrong codes of diseases and operations, we want to improve the veracity of the codes.

关 键 词：DRGS 疾病分类 编码错误原因 

分 类 号：R197.3[医药卫生—卫生事业管理]