病案书写质量对疾病编码的影响探析  

A Probe into the Influence of the Quality of Medical Record Writing on Disease Coding

作　　者：薛晓丽 XUE Xiaoli(Department of Medical Records,the Seventh People's Hospital of Dezhou City,Dezhou,Shandong Province,253009 China)

机构地区：[1]德州市第七人民医院病案科,山东德州253009

出　　处：《中国卫生产业》2021年第24期55-58,共4页China Health Industry

摘　　要：目的分析病案书写质量对疾病编码的影响。方法回顾性分析于2019年1—12月管理前,以及2020年1—12月管理后,不同时间段记录实施管理工作前后病案书写质量的改善差异。结果管理前发生疾病诊断书写错误3.03%(10/330)、病程记录不完整3.94%(13/330)、辅助检测不齐全6.97%(23/330);管理后编码正确率98.79%整体高于管理前86.06%,差异有统计学意义(P<0.05)。结论病案书写质量和疾病编码的符合率有着直接的关系,病案书写质量决定了疾病编码的准确性,通过疾病编码能够清晰反映出病案书写的质量。Objective To analyze the impact of the quality of medical record writing on disease coding.Methods A retrospective analysis of the improvement in the quality of medical record writing before and after the management from January to December 2019,and after the management from January to December 2020,was recorded at different time periods.Results 3.03%(10/330)of disease diagnosis and writing errors occurred before management,3.94%(13/330)of incomplete disease records,and 6.97%(23/330)of incomplete auxiliary testing;after management,the correct rate of coding was 98.79%and the overall high 86.06%before management,and the difference was statistically significant(P<0.05).Conclusion There is a direct relationship between the quality of medical record writing and the coincidence rate of disease code.The quality of medical record writing determines the accuracy of disease code.The quality of medical record writing can be clearly reflected by disease code.

关 键 词：病案书写质量 疾病编码 影响 

分 类 号：R19[医药卫生—卫生事业管理]