某院主要诊断编码正确率影响因素分析  

Analysis on the Influencing Factors of the Correct Rate of Main Diagnostic Codes in a Hospital

作　　者：李飞飞 屈小玲[2] LI Feifei;QU Xiaoling(Department of Medical Record Management,the First Affiliated Hospital of Baotou Medical College,Inner Mongolia University of Science and Technology,Baotou,Inner Mongolia Autonomous Region,014010 China;Department of Medical Record Management,Yichang Central People's Hospital,Yichang,Hubei Province,443000 China)

机构地区：[1]内蒙古科技大学包头医学院第一附属医院病案管理科,内蒙古包头014010 [2]湖北省宜昌市中心人民医院病案管理科,湖北宜昌443000

出　　处：《中国卫生产业》2021年第36期114-116,179,共4页China Health Industry

摘　　要：目的了解内蒙古自治区某三甲医院主要诊断正确率情况,分析其准确性,为持续提升病案首页主要诊断编码正确率提供决策支持。方法获取2021年第三季度住院病案首页12056份,通过编目前主要诊断与编目后主要诊断对比,根据《2021年国家医疗质量安全改进目标》中对主要诊断编码正确率的要求,通过电子病历分析系统对病案首页主要诊断编码情况进行统计分析。结果病案首页编码质量一级质控发现主要诊断选择及编码错误2283份,主要诊断编码正确率81.1%,针对一级质控后编码正确病历邀请专家进行二级质控核查,发现主要诊断编码正确病历中依然存在编码问题,主要有以下两个方面问题:①临床医师填写错误,编码员分类错误283份;②因临床医师填写正确,编码员分类错误77份。结论提升编码员疾病分类技能是提高主要诊断编码正确率的核心任务,科室需完善质控工作流程,结合质量管理工具进一步提高质控质量。Objective To understand the accuracy rate of main diagnosis in a tertiary hospital in Inner Mongolia Autonomous Region,analyze its accuracy,and provide decision support for continuously improving the accuracy rate of main diagnosis codes on the first page of medical records.Methods A total of 12056 front pages of inpatient medical records in the third quarter of 2021 were obtained,and the main diagnoses at present were compared with the main diagnoses after cataloguing.According to the"2021 National Medical Quality and Safety Improvement Goals"for the correct rate of major diagnostic codes.Statistical analysis was carried out on the main diagnostic codes on the homepage of medical records through the electronic medical record analysis system.Results The first-level quality control of coding quality on the first page of medical records found 2283 errors in the selection and coding of major diagnoses,and the correct rate of major diagnostic codes was 81.1%.Experts were invited to conduct a secondary quality control check for the medical records with correct coding after the primary quality control,and it was found that there were still coding problems in the medical records with the correct coding for the main diagnosis.There were mainly the following two problems:1.283 coder classification errors were caused by errors in filling by clinicians.2.Because the clinicians filled in correctly,the coders classified 77 copies incorrectly.Conclusion Improving the disease classification skills of coders is the core task to improve the correct rate of main diagnostic codes.Departments need to improve the quality control workflow and combine quality management tools to further improve the quality of quality control.

关 键 词：主要诊断 编码 病案首页 病案管理 疾病分类 

分 类 号：R19[医药卫生—卫生事业管理]