每月开展病案首页编码质量控制对提高编码质量的效果初探  

A preliminary Study on the Effect of Monthly Quality Control on Improving Clinical Coding on the Front Sheet of Medical Records

作　　者：周婧雅[1] 赵青[1] 廖爱民[1] 王怡[1] 刘海民[1] 朱瑞[1] 赵晓娟[1] 刘爱民[1] 

机构地区：[1]北京协和医院,北京市100032

出　　处：《中国病案》2017年第2期8-11,48,共5页Chinese Medical Record

摘　　要：目的评价每月开展编码质量控制工作对某院提高编码质量的效果。方法 2015年4月至2016年4月(除外2016年2月),依托某院用于病案内涵质量评价的病历样本,每月由专人对住院病案首页中出院诊断、手术及操作编码质量进行评价,并将质控结果在科内质量安全会议中公示总结,并针对问题开展培训。分析一年内每两个月各类编码错误率的变化趋势,以评价编码质量改善效果。结果总体编码错误率在编码质控开展前后差异不大(10.7%vs10.7%),主要诊断错误率、其他诊断错误率、主要手术/操作及其他手术/操作错误率各个指标的各点变化趋势经卡方趋势检验分析,均无统计学意义,P>0.05。"肿瘤部位编码与病理结果不符"是主要诊断编码错误最主要类型,而主要手术/操作错误以细目水平编码错误为主,其他诊断和其他手术/操作错误均以遗漏编码为主。结论某院编码质量保持着较高水准,在此基础上通过每月开展编码质控工作进一步提高难度较大,仍需探索如结合专题质控等其他编码提升策略。Objective To evaluate the effect of monthly quality control on improving large teaching hospital. Methods Supported by the convenient samples of medical Front Sheet of Xiaojuan, Liu clinical coding quality in a records for writing quality assessment, inspection of clinical coding quality along with error-based training and discussion was carried out from April 2015 to April 2016 （except February two months in order to evaluate its effect on 2016）. We analyzed the changing tendency of the coding error rate every coding quality improvement. Results The overall coding error rate before and after quality control was 10. 7% and 10. 7%, the error rate of principal diagnosis, other diagnosis, principal operation or procedure and other operations or procedures all appeared no significant change by X 2 tendency test, P〈0. 05. ＂Tumor location code and histopathology matching error＂ was the main type error of principal diagnosis, error in the fourth digit leads to most error of principal operation / procedure, and major coding error type other diagnosis and other operations and procedures was omitting. Conclusion Accuracy of clinical coding of both in our hospital had been maintained at a relatively high level. It is still necessary to explore more comprehensive strategies, such as the combination of specialty quality control for improving clinical

关 键 词：质量控制 效果 ICD 编码 病案首页 

分 类 号：R197.323[医药卫生—卫生事业管理]