病案书写质量对疾病编码正确性的影响  

作　　者：孙素青 

机构地区：[1]首都医科大学大兴教学医院,北京102600

出　　处：《中国药业》2020年第S02期203-204,共2页China Pharmaceuticals

摘　　要：目的探讨加强病案书写质量管理对提高疾病编码正确性的影响。方法选取医院2016年12月至2017年12月实施质量管理前的病案为对照组,另取2018年1月至2019年1月实施质量管理后的病案为研究组,各500份。比较两组病案书写质量和疾病编码正确性,分析造成疾病编码错误的原因。结果与对照组比较,研究组病案书写质量明显升高(P<0.05),疾病编码正确性显著升高(P<0.05)。病案书写中疾病名称书写不规范为影响疾病编码正确性的主要原因。结论实施病案书写质量管理后,医务人员病案书写质量得到明显提升,疾病编码正确性显著提高。Objective To investigate the influence of strengthening the quality management of medical record writing on improving the correctness of disease coding.Methods The medical records from December 2016 to December 2017 before the implementation of quality management were selected as the control group,and the medical records from January 2018 to January 2019 after the implementation of quality management were selected as the study group,500 records in each group.The writing quality of medical records and the correctness of disease coding were compared between the two groups,and the causes of disease coding errors were analyzed.Results Compared with those in the control group,the writing quality of medical records in the study group was significantly higher(P<0.05),and the correctness of disease coding in the study group was significantly higher(P<0.05).The nonstandard writing of disease name is the main reason that affects the correctness of disease coding.Conclusion After the implementation of quality management of medical record writing,the quality of medical record writing of medical staff has been significantly improved,and the correctness of disease coding has been significantly improved.

关 键 词：病案资料 疾病编码 书写质量 疾病名称 正确性 

分 类 号：R95[医药卫生—药学]