病案书写质量对医院疾病编码正确性的影响研究  

Research on the Influence of Medical Record Writing Quality on the Correctness of Hospital Disease Coding

作　　者：梁少庆 LIANG Shaoqing(Department of Medical Records,Dongguan Donghua Hospital,Dongguan,Guangdong Province,523110 China)

机构地区：[1]东莞东华医院病案科,广东东莞523110

出　　处：《中国卫生产业》2021年第9期67-69,共3页China Health Industry

摘　　要：目的分析其书写质量可能会对编码正确性带来的影响。方法该研究以2019年6月—2020年6月为研究的时间界限,对期间该院由于病案书写质量问题而导致编码错误的案例资料100份进行回顾性分析,找到出现书写质量问题的原因所在,并制定出针对性的改进性意见与建议。结果分析显示,导致疾病编码不正确的病案书写质量原因有很多,其中常见的有首页诊断书写缺乏规范性、体格检查不符合患者病史内容、对病程记录的书写不完整、对手术记录的书写不全面、未填写根本死亡原因或死亡原因选择错误、没有把辅助性检查报告单纳入到病历之中等。其中首页诊断书写缺乏规范性是最为主要的原因,占比40.0%。结论病案书写质量与疾病编码正确与否直接相关,同时亦会严重影响患者的诊断过程与治疗结果,并且通过疾病编码还可以从侧面对病案书写质量进行有效反映,以上两者之间存在着非常紧密的关联,应引起高度关注与重视。Objective To analyze the impact that the quality of writing may have on the correctness of coding.Methods This study uses June 2019 to June 2020 as the research time limit.During the period,100 cases of coding errors in the hospital due to the quality of medical record writing were retrospectively analyzed to find the reasons for the writing quality problems.And formulate targeted suggestions and suggestions for improvement.Results Aanlysis display,it could be seen that there were many reasons for the quality of the medical record writing that cause the disease code to be incorrect.The common ones were the lack of standardization of the diagnosis writing on the front page,the physical examination does not conform to the patient's medical history content,and the record of the course incomplete writing,incomplete writing of surgical records,failure to fill in the underlying cause of death or wrong selection of the cause of death,failure to include the auxiliary examination report in the medical record,etc.The lack of standardization of diagnosis writing on the front page was the most important reason,accounting for 40.0%.Conclusion The quality of medical record writing is directly related to whether the disease code is correct or not,and it will also seriously affect the patient's diagnosis process and treatment results,and the disease code can also effectively reflect the quality of medical record writing from the side.There is a very close relation between the two and shold arouse great attention and attention.

关 键 词：病案书写质量 疾病编码 病案资料 国际疾病分类 正确性 

分 类 号：R7[医药卫生—临床医学]