300份骨科病案出院诊断与手术操作填写缺陷分析  

Analysis of Discharge Diagnosis and Defects of Operation Filling in 300 Orthopaedic Medical Records

作　　者：郭斌[1] 刘新奎[1] 刘宏建[2] Guo Bin;Liu Xinkui;Liu Hongjian(Department of Medical Record Management,The First Affiliated Hospital of Zhengzhou University,Zhengzhou 450052,Henan Province,China;不详)

机构地区：[1]郑州大学第一附属医院病案管理科,河南省郑州市450052 [2]郑州大学第一附属医院骨科,河南省郑州市450052

出　　处：《中国病案》2021年第9期10-12,共3页Chinese Medical Record

摘　　要：目的分析住院病案首页中出院诊断、手术操作及其编码中的错误,并提出改善措施。方法采取计算机随机抽取2019年1月1日-2019年12月31日300份骨科住院病案首页中出院诊断与手术操作进行回顾性分析,统计主要诊断、其他诊断、主要手术操作,其他手术操作填写的相关错误,以及错误的原因。结果临床医师的主要诊断错误率为21.5%,其他诊断错误率为30.0%。编码员的主要诊断编码错误率为4.2%,其他诊断编码错误率为3.5%。常见错误原因有临床医师诊断不准确、其他诊断遗漏、诊断与手术不符、编码与诊断不符及编码遗漏。临床医师的主要手术操作错误率为14.2%,其他手术操作错误率9.5%。编码员的主要手术操作错误率为3.5%,其他手术操作编码错误率2.5%。常见出错原因有临床医师手术操作名称遗漏、手术操作名称与实际操作不符、次要操作缺失、编码与手术操作不符、未精细编码及编码遗漏。结论病案首页中出院诊断与手术操作填写缺陷主要包括临床医师填写遗漏和填写错误,以及编码与诊断和手术操作不符。可通过加强对临床医师的培训、建全医师与编码员沟通机制等措施进一步提高病案首页书写的准确率。Objectives To analyze coding errors and propose improvement by collecting discharge diagnosis and surgery/operation from 300 orthopedic medical records.Methods 300 samples of the hospital’s orthopedics department from January 1st,2019 to December 31st,2019 were retrospectively analyzed for discharge diagnosis and surgery/operations on the home page of the inpatient medical record.The error of main diagnoses,other diagnoses,major operations,and other operations were recorded,the reason for the error were analyzed.Results The incorrect rate of main diagnosis by clinicians was 21.5%,and the incorrect rate of other diagnoses was 30.0%.The incorrect rate of the main diagnostic codes was 4.2%,and the incorrect rate of other diagnostic codes was 3.5%.The inaccuracy rate of clinicians’main surgery/operation was 14.5%,and the inaccuracy rate of other operations was 9.5%.The incorrect rate of the main operations of the coders was 3.5%,and the incorrect rate of other operations was 2.5%.Conclusions The deficiencies in the discharge diagnosis and surgical operation on the front page of the medical record mainly include omissions and errors in filling in by the clinician,as well as the inconsistency of the coding with the diagnosis and the operation.The accuracy of writing the front page of medical records could be further improved by strengthening the training of clinicians and establishing a communication mechanism between physicians and coders.

关 键 词：住院病案首页 出院诊断 手术操作编码 病案质控 

分 类 号：R197.323[医药卫生—卫生事业管理]