黑龙江省某三甲医院住院病案首页ICD编码质量分析  

Quality Analysis of Medical Record Coding in a Top Three Hospital in Heilongjiang Province

作　　者：刘怡 郑旭东[2] 张季[1] Liu Yi;Zheng Xudong;Zhang Ji(The Fourth Affiliated Hospital of Harbin Medical University,Harbin 150000,Heilongjiang Province,China;不详)

机构地区：[1]哈尔滨医科大学附属第四医院,黑龙江省哈尔滨市150000 [2]哈尔滨医科大学附属第二医院,黑龙江省哈尔滨市150000

出　　处：《中国病案》2020年第10期18-21,共4页Chinese Medical Record

摘　　要：目的通过对黑龙江省某三甲医院2019年上半年出院患者的住院病案首页ICD编码进行监测,核查住院病案首页的疾病诊断和手术操作编码准确性,分析错误原因并提出整改建议,旨在提高住院病案首页编码质量和管理水平。方法采用分层系统抽样的方法,对2019年1月1日-2019年6月30日出院病案9870份进行抽查,并核查住院病案首页的疾病诊断和手术操作的ICD编码情况,进行描述性统计分析。结果2019年1月-6月,编码员平均每日编码住院病案首页115份左右,每月25日后编码的病案数占全月总病案数的比例均大于40%。抽查9870份出院病案中,错误编码的病案为740份,占7.50%。从整体上来看,2019年上半年病案编码的错误率呈现稳定下降的趋势。在所有病案编码缺陷中,疾病诊断的错编出现次数最多,共计198条,占总缺陷数目的32.35%,其次为手术及操作的错编,占29.41%。疾病诊断的漏编情况主要为产科Z-编码:分娩结局及M肿瘤形态学的编码。错误编码的主要原因在于编码员对编码专业技能欠熟悉,占42.40%。结论加强编码员的编码业务能力、制定合理的编码员轮换制度和减负制度、加强临床医师病历书写能力,定期对住院病案首页ICD编码进行质量检测,从而提高病案编码的准确性。Objective To analyze the reasons for the lack of items and put forward some suggestions for improvement through the examination of the medical records of the first half of 2019 discharged from a top three hospital in Heilongjiang Province.Methods Stratified systematic sampling method was used to check the medical records of the whole hospital discharged from January to the first half of June 2019,check the disease code and operation code,and classify and analyze them one by one.Results From January to June 2019,the average number of medical records encoded by the coders in a hospital was about 105 per day,and the number of medical records encoded after the 20 th day of each month accounted for more than 40%of the total number of medical records in the whole month.Among 9870 medical records,740 were wrongly coded,accounting for 7.50%.On the whole,the error rate of medical record coding in the first half of 2019 shows a stable downward trend.Among all the coding defects of medical records,the number of wrong coding of disease diagnosis is the most,198 in total,accounting for 32.35%of the total number of defects,followed by the wrong coding of operation and operation,accounting for 29.41%.The missed cases of disease diagnosis are mainly Z-coding in obstetrics:the coding of delivery outcome and m-tumor morphology.The main reason of wrong coding is that coders are not familiar with coding professional skills,accounting for 42.40%.Conclusion It is effective to find out the problems in the process of medical record coding and improve the accuracy of medical record coding by strengthening the coder’s coding ability,establishing a reasonable coder rotation system and burden reduction system,strengthening the ability of clinical medical record writing,and regularly testing the quality of medical record coding.

关 键 词：病案首页 ICD编码 质量分析 

分 类 号：R197.323[医药卫生—卫生事业管理]