疾病编码质量的分析研究与对策  

Analysis Research and Strategies of the Quality of Medical Record Coding

作　　者：马茹君[1] 纪艳[1] 孙国梅[1] 

机构地区：[1]安徽医学高等专科学校公卫系,安徽合肥230601

出　　处：《安徽卫生职业技术学院学报》2017年第6期6-7,共2页Journal of Anhui Health Vocational & Technical College

基　　金：2017年安徽省教育厅人才资助项目(编号:qxyq2017204);2015年安徽省教育厅教学研究项目(编号:2015jyxm446)

摘　　要：目的:通过对病案疾病编码质量的分析,旨在提出提高疾病编码的准确性的对策,以此促进病案科工作效率和医院信息服务质量。方法:根据国际疾病分类的编码原则,随机从合肥本地省级和市级两家综合性医院2016年7月份出院的病案中抽取各500份病案进行编码检查。结果:1000份病案中,主要诊断选择、编错疑难病编码和肿瘤编码错误率占22.6%、19.8%和16.3%。结论:应加强、更新编码员的专业知识以及相关临床知识的培训,加强病案编码质量日常控制和工作质量绩效考核。Objective：Through the analysis of the quality of medical record coding, the aim is to propose strategies to improve the accuracy of disease coding, So as to promote the efficiency of medical records and the quality of hospital information service.Method：According to the coding principles of international classification of diseases, Randomly selected 500 medical records from the local, provincial and municipal hospitals in Hefei in 2016 and July.Result：In 1000 medical records, The main diagnostic options, coding errors, coding errors, and tumor coding errors were 22.6%, 19.8% and 16.3%.Conclusion：It is essential to strengthen and update the coding specialist＇s knowledge and clinical knowledge training, and strengthen performance appraisal to evaluate daily work quality.

关 键 词：疾病编码 质量分析 质量控制 

分 类 号：R197.3[医药卫生—卫生事业管理]