某院主要诊断和主要手术编码错误分析  

Analysis of Major Diagnostic and Major Surgical Coding Errors in a Hospital

作　　者：陈淡芬 吴妙婷[1] 刘瑞芬 Chen Danfen;Wu Miaoting;Liu Ruifen(The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, Guangdong Province, China)

机构地区：[1]中山大学附属第五医院,广东省珠海市519000

出　　处：《中国病案》2019年第5期28-30,共3页Chinese Medical Record

摘　　要：目的分析基于按病种付费的某院病案首页主要诊断和手术编码存在的问题,提出改进的方法。方法根据主要诊断填报指南及国际疾病编码规则,对2018年1月-2018年6月出院病案采用等距随机抽样筛选的方法,抽取10%病案3561份,逐一审核,并将结果进行统计分析。结果主要诊断或手术选择错误共98例,总错误率为2.75%。其中主要诊断选择错误74份,错误率最多,占75.5%;主要手术选择错误19例,占19.4%;主要诊断和手术均选择错误5例,占5.1%。医师主要诊断或主要手术选择错误,编码员同错的有83处,占错误比例80.6%,医师主要诊断或主要手术选择对,编码员改错的有20处,占错误比例19.4%。主要诊断编码错误率居第1的是没有以病因作为主要诊断,主要手术编码错误率位居第1的是编码员的水平问题。结论病案首页中主要诊断和主要手术的选择要求临床医师应充分了解主要诊断和手术选择的标准,熟悉当地医保政策,严格填写病案首页、编码员要认真审核病案首页、掌握编码原则,加强临床相关专业知识的学习,同时建立良好的沟通和质控机制。Objectives To analyze the problems existing in the diagnosis and operation coding of a hospital based on the disease species payment, and propose an improved method. Methods According to the main diagnostic reporting guidelines and the international disease coding rules, the medical records of extracted In the first half of 2018 by the system sampling method were reviewed one by one, and the results were statistically analyzed. Results In the 3561 medical records, 98 cases were mainly wrong in diagnosis or operation, and the total error rate was 2.75%. Among them, the proportion of major diagnostic errors was the highest(75.5%), and that of the doctors was mainly wrong, and that of the coders was the most, accounting for 81.6% of the main diagnostic errors.Conclusions The selection of major diagnosis and operation in the front pages of medical records requires clinicians to fully understand the criteria of major diagnosis and surgical selection, to be familiar with local medical insurance policies, to fill in the front pages of medical records strictly, and to carefully examine the front pages of the medical records. Master coding principles, strengthen clinical related professional knowledge to learn and establish good communication with doctors.

关 键 词：主要诊断 主要手术 编码 疾病诊断相关分组(DRGs) 医保付费 

分 类 号：R197.323[医药卫生—卫生事业管理]