病案首页ICD编码质量控制及改进措施  

Quality Control and Improvement Measures of ICD Coding on the Homepage of Medical Records

作　　者：杨玉营 YANG Yuying(Department of Medical Record Statistics,The Fourth Affiliated Hospital of Nanjing Medical University,Nanjing Jiangsu 210000,China)

机构地区：[1]南京医科大学第四附属医院病案统计室,江苏南京210000

出　　处：《中国卫生标准管理》2021年第19期7-10,共4页China Health Standard Management

摘　　要：目的研究开展病案首页国际疾病分类(international classification of diseases,ICD)编码质量控制工作对提高医院编码质量的效果。方法选取2018年5月—2019年4月,根据笔者所在医院用于病案内涵质量评价的病历样本,由专人对病案首页中的出院诊断、手术、操作、编码质量等进行评价,在科内质量安全会议中公示总结的质控结果,根据问题进行培训。分析1年内,每2个月各类编码错误率的变化趋势,以评价改善效果。结果总体编码错误率在编码质控开展前与开展后差异不大,主要错误各指标变化比较,P>0.05;主要诊断编码错误的类型为肿瘤部位编码和病理结果不相符。结论本院编码质量向来保持较高水准,通过每月开展编码质控工作很难提高,需结合专题质控及其他编码提升编码质量。Objective To study the effect of ICD coding quality control on the first page of medical records on improving the quality of hospital coding.Methods From May 2018 to April 2019,according to the medical record samples used by the hospital for the quality evaluation of the medical record,a dedicated person evaluated the discharge diagnosis,surgery,operation,coding quality,etc.on the medical record homepage,and publicized the summarized quality control results in the internal quality and safety meeting,training according to the problem.Analyzed the change trend of various coding error rates every two months within one year to evaluate the improvement effect.Results The overall coding error rate was not significantly different before and after the coding quality control was carried out.The main errors were compared with each index change,P>0.05;the main type of diagnosis coding error was the inconsistency of the tumor site coding and the pathological results.Conclusion The coding quality of our hospital has always been maintained at a high level.It is difficult to improve the coding quality through monthly coding quality control work.It is necessary to improve the coding quality in combination with thematic quality control and other coding.

关 键 词：病案 ICD编码 质量控制 改进措施 诊断 病理 

分 类 号：R197[医药卫生—卫生事业管理]