公立医院绩效考核背景下某医院病历档案首页常见问题分析  

Analysis of Common Problems on the First Page of Medical Records of a HospitalUnder the Background of Performance Assessment in Public Hospitals

作　　者：李增芳 丁松瑞 赵敏[1] 张春宏[1] LI Zeng-fang;DING Song-rui;ZHAO Min;ZHANG Chun-hong(The Third Affiliated Hospital of Kunming Medical University/Yunnan Cancer Hospital/Yunnan Cancer Center,Kunming 650118,Yunnan,China)

机构地区：[1]昆明医科大学第三附属医院/云南省肿瘤医院/云南省癌症中心,云南昆明650118

出　　处：《医学信息》2020年第22期145-146,共2页Journal of Medical Information

基　　金：云南省哲学社会科学研究基地课题(编号:JD2018YB10)。

摘　　要：目的了解某医院病案首页填报现状,探究病案首页的重要性。方法通过案例分析法,回顾总结某医院2019年1~12月98264例患者病案首页质控中存在的问题。结果某医院的病案首页填写存在不足,ICD-10疾病编码和ICD-9手术及操作编码也存在明显不足,其中疾病编码选择错误最多,为16.92%,其次为主要诊断选择错误,占15.07%。结论针对病案首页填写疾病与手术操作ICD编码缺陷等情况,应采取多举措提高病历档案质量,保证填写的准确性与完整性。在医院、临床医生、病案管理科编码人员共同努力下做好病案首页填写工作。Objective In order to understand the status on the first page of medical records and explore the importance on the first page of medical records.Methods Via case analysis method,the common problems in the first page of medical records of 98264 patients from January to December 2019 were reviewed and summarized.Results There is obvious deficiency in filling in the first page of medical records in the hospital.The ICD-10 disease code and the ICD-9 surgery and operation code are also significantly inadequate.Disease coding error accounted for 16.92%,followed by major diagnostic error accounting for 15.07%.Conclusions According to the status of filling in problems on the first page of medical records,diseases and surgical operations ICD coding defects,a hospital has taken many measures to improve the quality of medical records and ensure the accuracy and completeness of filling in records.Only with the joint efforts of clinicians and coders of the medical record management department,the writing first page of medical records can be done well.

关 键 词：医院绩效考核 ICD编码 病历档案 

分 类 号：R197[医药卫生—卫生事业管理]