690份新生儿科病案编码质量分析  

Coding Quality Analysis of 690 Neonatal Medical Records

作　　者：刘慧悦[1] 周柳英[1] 曾芳[1] Liu Huiyue;Zhou Liuying;Zeng Fang(Center for Medical Record Management and Information Statistics,Xiangya Hospital,Central South University,Institute of Hospital Management,Central South University,Changsha 410008,Hunan Province,China;不详)

机构地区：[1]中南大学湘雅医院病案管理与信息统计中心中南大学医院管理研究所,湖南省长沙市410008

出　　处：《中国病案》2020年第11期25-28,共4页Chinese Medical Record

基　　金：中南大学湘雅医院医院管理研究基金项目(2019GL11)。

摘　　要：目的检查某院新生儿科病案编码质量,进行统计分析并找出影响因素,进而提高编码质量。方法按照15%的比例对2018年1月1日-2019年12月31日全院新生儿科出院病案4602份进行随机抽查,核查疾病诊断与手术操作编码,进行统计分析。结果690份病案中编码存在错误的有38份,占5.5%。其中问题最为突出的是错编其他诊断73.9%、主要诊断选择错误13%、错编主要诊断10.9%等。最主要的原因是编码员未仔细阅读病案(41.3%),其次为编码员粗心大意(23.9%)、编码员不熟悉编码库和编码规则(21.7%)等。结论规范临床医师书写标准、提高编码员的知识水平、利用智能监测系统辅助人工质控有利于提高病案编码质量,为医院提供准确的数据支撑。Objectives To test the coding quality of Neonatal medical records of a hospital,analysis the reasons causing wrong coding,explore the methods of improving coding accuracy.Methods According to the proportion of 15%,4602 cases of discharged medical records from neonatal unit in 2018-2019 were randomly selected,inspect and analysis the diseases and operations coding situation.Results 38 out of 690 medical records were coded incorrectly,accounting for 5.5%.The most prominent problems are 73.9%of other diagnostic error codes,13.0%of main diagnostic error selections,10.9%of main diagnostic error codes,etc.The results showed that the main reason was that the coder didn’t read the medical record carefully(41.3%),followed by the coder’s carelessness(23.9%),the coder was not familiar with the coding library and coding rules(21.7%).Conclusions Standardizing the writing standards of clinicians,improving the knowledge level of coders,and using intelligent monitoring system to assist artificial quality control are conducive to improving the quality of medical record coding,and providing accurate data support for hospitals.

关 键 词：病案编码 质量检测 新生儿 

分 类 号：R197.323[医药卫生—卫生事业管理]