住院病案首页数据编码质量的改进分析  

Analysis on the Quality Improvement of the Coding of the Medical Record Front Pages

作　　者：赵学英[1] 杨冬梅[1] 王巍[1] 徐锡武[1] 

机构地区：[1]北京医院,北京市100730

出　　处：《中国病案》2016年第6期4-6,共3页Chinese Medical Record

摘　　要：目的通过分析某院2014年与2015年住院病案首页数据专项督导检查中抽检的病案首页编码情况,对比改进措施前后的病案编码质量,评价改进效果。方法回顾某院2014年与2015年抽检的200份与150份病案首页编码情况,核对病案首页与病案实际内容填写检查表,比较病案首页的编码质量。结果某院采用5项加强病案编码质量与控制措施,包括病案首页编码时核对病案相关记录内容,主要手术编码与主要诊断编码前后一致对应,编码员每日抽检20%编码病案互查核对,每周进行集体编码业务讨论学习,编码员与医师沟通确定疑难编码。分析显示2015年病案首页质量有显著性提高。结论病案科需要加强编码质量的管理,完善编码质控流程。编码核对以及及时学习反馈,医师与编码员的互通是提高病案首页编码质量的关键。Objective To analyze the coding of the medical record front pages from the special supervision in 2014 and 2015. To compare the medical record coding quality before and after the improvement measures, and evaluate the efficacy of the improvement. Methods Review the coding of 200（2014） and 150（2015） medical record front pages, and check the medical record with medical record front page and fill in check lists. Compare the medical record front page coding quality. Results The hospital adopted five measures to strengthen medical record coding quality, including check the medical records when coding, the major surgery coding is consistent with the main diagnosis, Coders daily choose and check 20% medical record, Collective discussion weekly, coders communicate with physicians to determine codes. Analysis showed that the quality of medical record front page has a significant increase in 2015. Conclusion The medical record department needs to improve management of the quality of coding, and coding quality control procedure. The communication between physician and coders is the key to improve the quality of medical record front page coding.

关 键 词：病案首页数据 编码质量 改进措施 

分 类 号：R197.323[医药卫生—卫生事业管理]