构建模块化ICD和手术操作分类工作对病案信息管理的影响  

The Influence of the Construction of Modular ICD and the Classification of Surgical Operations on Medical Record Information Management

作　　者：朱桂玲 ZHU Gui-ling(Guangzhou Panyu Central Hospital,Guangzhou 511400,Guangdong Province,P.R.C.)

机构地区：[1]广州市番禺区中心医院,511400

出　　处：《中国数字医学》2020年第11期105-108,116,共5页China Digital Medicine

摘　　要：目的:分析模块化ICD和手术操作分类工作对病案信息管理的影响。方法:随机选取我院2017年7月到2018年7月共1557份病历,分为干预组779例和对照组778例,对照组应用常规国际疾病分类(ICD)及手术操作分类编码工作,干预组应用模块化ICD和手术操作分类编码工作,比较两组病案信息的诊断编码错误率、首页质量合格率、归档标准率、医疗纠纷发生率等情况,同时比较两组病案信息所用的平均耗时时间及管理人员对模块化工作评价的满意度。结果:干预组病案信息诊断编码错误率、首页质量合格率、归档正确率及医疗纠纷发生率明显优于对照组,差异存在统计学意义(P<0.05);干预组病案信息管理平均时间低于对照组(P<0.05);管理人员填写的满意度报告显示,干预组满意度(96.3±1.7)明显高于对照组(79.7±1.5)(P<0.05)。结论:构建模块化ICD和手术操作分类工作明显提高了病案信息诊断编码的正确率,改善了首页质量及归档正确率,信息管理时间明显缩短,提高了病案管理人员的质控情况及满意度,值得推广与应用。Objective:To explore the influence of modular ICD and surgical operation classification on medical record information management.Methods:A total of 1557 medical records from July 2017 to July 2018 were randomly selected and divided into intervention group(779 cases)and control group(778 cases).The control group was used conventional international classification of diseases(ICD)and the classification coding operation,intervention group applications modular ICD and operation classification coding.We comparied the two groups with medical record information file diagnostic code error rate,the home page of quality,standard rate,incidence of medical disputes,and so on and so forth,at the same time,the average used to compare two groups of medical record information takes time,and the evaluation of the management of modular work satisfaction.Results:The error rate of medical record information diagnosis coding,the qualified rate of front page,the correct rate of filing and the incidence of medical disputes in the intervention group were significantly better than those in the control group(P<0.05);the average time of medical record information management in the intervention group was lower than that in the control group(P<0.05);the satisfaction report filled by the managers showed that the satisfaction of the intervention group(96.3±1.7)was significantly higher than that of the control group(79.7±1.5)(P<0.05)。Conclusion:The construction of modular ICD and surgical operation classification can significantly improve the accuracy of diagnostic coding of connection board,the quality of the first page and the accuracy of archiving.It significantly shorten the time of information management,and generally improve the quality control and satisfaction of the following staff,which is worthy of extensive promotion and application.

关 键 词：ICD 手术操作分类 模块化 病案信息 

分 类 号：R319[医药卫生—基础医学]