三级病案编码质控体系实践效果分析  

The Practice of the Three-Level Quality Control System of Medical Records Coding

作　　者：李继志 祝中华 肖耀俊 刘仁英 邓川 孙光冶 LI Jizhi;ZHU Zhonghua;XIAO Yaojun(Liangping District People's Hospital of Chongqing,Chongqing,401120,China)

机构地区：[1]重庆市梁平区人民医院

出　　处：《中国卫生质量管理》2019年第6期42-44,共3页Chinese Health Quality Management

摘　　要：目的建立三级病案编码质控体系,探讨应用效果。方法2016年使用常规方法进行病案编码质控,2017年采用三级病案编码质控,由重庆医科大学附属第二医院的专家每月随机抽查5%出院病案进行比较;同时,对2016年、2017年病案室编码人员进行编码知识测评。结果2017年抽检危重症病例病案编码、三四级手术病例病案编码、病案首页编码合计正确率均高于2016年,差异有统计学意义(P<0.05);但疑难病例病案编码、纠纷病例病案编码与2016年比较,差异无统计学意义(P>0.05)。2017年编码人员编码能力考核评分也高于2016年,差异有统计学意义(P<0.05)。结论三级病案编码质控体系可提高病案编码质量,提升编码人员业务能力,有一定推广价值。Objective To establish a three-level medical records coding quality control system and explore the application effect.Methods In 2016,routine method was used for medical records coding quality control,and in 2017,third-level medical record coding quality control was adopted,and 5%of discharged medical records were randomly checked by the second affiliated hospital of Chongqing Medical University every month for comparison.Furthermore,the coding knowledge of the coding staff in the Department of Medical Records in 2016 and 2017 was evaluated.Results In 2017,the total accuracy of the coding of the critical cases,the coding of the third-level and fourth-level surgical cases,and the coding of the first page of the medical records were all higher than those of 2016,and the difference was statistically significant(P<0.05).However,there was no significant difference in the coding of difficult cases and dispute cases(P>0.05).The coding ability assessment score of the coders in 2017 was also higher than that in 2016,with a statistically significant difference(P<0.05).Conclusion The application of the three-level medical records coding quality control system can improve the quality of medical records coding and enhance the professional ability of the coding staff,it has a certain promotion value.

关 键 词：病案 编码 三级质控 

分 类 号：R197.323[医药卫生—卫生事业管理]