某院2019年出院病案疾病编码质量分析  

Analysis of Disease Coding Quality of Discharged Medical Records in a Hospital in 2019

作　　者：李几幂[1] Li Jimi(People’s Hospital of Tibet Autonomous Region,Lhasa 850000,Tibet Autonomous Region,China)

机构地区：[1]西藏自治区人民医院,西藏自治区拉萨市850000

出　　处：《中国病案》2022年第2期13-16,共4页Chinese Medical Record

摘　　要：目的 分析某院2019年出院病案疾病编码错误,目的在于提高该院出院病案疾病编码的准确性,进一步提高医院住院病案首页数据质量。方法 由年资高(编码工作15年以上)、专业技术强的3名编码员和1名医疗质控员组成的4人住院病案首页质控专家小组,共同核查从2019年1月1日-12月31日出院病案23 360份,利用系统抽样法(按照20%抽查比例),抽查了4672份出院病案,根据国际疾病(ICD-10第二版)分类方法,重新核对样本的疾病诊断编码,通过Excel(2019版)表格详细记录疾病编码错误及原因,进行回顾性统计分析,并在这一基础上制定相关的改进措施。结果 抽样4672份病案中疾病编码错误共428份,错误率为9.2%。其中主要诊断编码错误率为42.53%、其他诊断编码错误率为29.85%、漏编其他诊断编码错误率为17.66%。结果显示主要诊断编码错误的前五位疾病是:累及身体多处损伤占35.51%、相邻部位及多部位恶性肿瘤占20.56%、涉及产科情况及梗阻性分娩占16.82%、脑出血疾病占14.02%、高血压是否伴有心衰和肾衰及继发性高血压占10.75%等。疾病编码错误原因分别为:临床医师住院病案首页诊断填写不规范,占37.5%;编码员不了解疾病性质,占32.8%;编码员不熟悉疾病编码规则,占20%。结论 疾病诊断编码涉及主要诊断编码及其他诊断编码,主要诊断编码、其他诊断编码的准确与否,直接影响到病案疾病编码的准确性。医院应注重加强编码员临床医学知识的学习、提高编码员的专业水平,提高临床医师住院病案首页填写质量。Objective To improve the accuracy of the disease coding in the discharge medical records of a hospital in 2019,and to further improve the quality of the first page data of the inpatient medical records.Methods A four-person medical record first page quality control expert group composed of three coders with high experience(more than 15 years of coding work) and strong professional skills and one medical quality controller jointly checked 23360 hospital records from January 1 to December 31,2019,and 4672 discharged cases were checked by using systematic sampling method(according to 20% sampling ratio).According to the classification method of International Diseases(ICD-10 second edition),the disease diagnostic codes of the samples were rechecked,and the errors and causes of the disease coding were recorded in detail in Excel(2019 edition) form,and retrospective statistical analysis was conducted,and relevant improvement measures were formulated on this basis.Results Among the 4672 medical records,there were 428 errors in disease coding,with an error rate of 9.2%.Among them,the coding error rate of main diagnosis was 42.53%,the coding error rate of other diagnosis was 29.85%,and the coding error rate of omission of other diagnosis was 17.66%.The results showed that the top five diseases with wrong diagnosis codes were:multiple body injuries(35.51%),adjacent sites and multiple sites malignant tumors(20.56%),obstetric conditions and obstructive delivery(16.82%),cerebral hemorrhage(14.02%),hypertension accompanied by heart failure and renal failure(10.75%) and secondary hypertension(10.75%).The causes of disease coding errors were as follows:the first page of diagnosis was not filled in standard by clinicians,accounting for 37.5%;The coders did not understand the nature of the disease,accounting for 32.8%;Coders are not familiar with disease coding rules,20%.Conclusion The disease diagnosis code involves the main diagnosis code and other diagnosis codes.The accuracy of the main diagnosis code and other diagnosis codes

关 键 词：住院病案首页 疾病编码 错误 改进措施 

分 类 号：R197.323[医药卫生—卫生事业管理]