某院病案编码质量培训前后的变化分析  

Change Analysis on the Coding Quality of Medical Records in a Hospital Before and After the Training

作　　者：董淑静[1] 刘笑成 李磊[1] 石静[1] 刘妍 

机构地区：[1]河北省南皮县人民医院,南皮县061500

出　　处：《中国病案》2017年第9期39-41,共3页Chinese Medical Record

摘　　要：目的探讨系统培训学习对病案编码质量的影响。方法将2015年10月-2016年9月培训学习后完成病案编码的出院病例作为研究组,将2014年9月-2015年8月培训学习前完成的病案编码的出院病例作为对照组,对比两组病例的疾病编码总条目数、统计病种数、残余类目数、手术操作病例数、手术操作总条目数。结果研究组的平均每出院人数编码条目数较对照组增加,统计病种数增加,其中残余类目条目数有明显下降,差异有明显统计学意义,研究组平均每出院人数手术操作编码条目数、手术操作编码的病例数明显高于对照组,操作编码增加明显,存在统计学差异。结论系统培训学习掌握编码基本原则是提高病案编码质量的有效方法和途径。Objective To explore the effect of systematic training and learning on the quality of medical record coding. Methods The discharge cases were recorded as the study group, and the patients who had completed the coding of the medical records were taken as the control group. The total number of disease codes, the number of diseases; the number of residual categories, the number of surgical procedures, the total number of surgical procedures. Results The average number of disease coding items in study group increased compared with control group, the statistical disease species increased, the residual category number decreased significantly, there was statistical significance. The average number of disease coding items in study group was significantly higher than the control group, the total number of operation coding increased, there was significant difference. Conclusions It was an effective way to improve the coding quality of medical record by mastering the basic principles of coding through systematic training and learning.

关 键 词：培训 编码质量 变化分析 

分 类 号：R197.323[医药卫生—卫生事业管理]