手术相关病案的编码缺陷质控方法及效果分析  

Quality control method and effect analysis of coding defects in surgical related medical records

作　　者：谷玉婷 谭智[1] 蒋南 翁俊 GU Yuting;TAN Zhi;JIANG Nan;WENG Jun(The First Affiliated Hospital of Sun Yat-sen University,Guangzhou 510080,China)

机构地区：[1]中山大学附属第一医院,广东广州510080

出　　处：《现代医院》2022年第9期1387-1390,共4页Modern Hospitals

摘　　要：目的 为提高国际疾病和手术操作分类编码质量,某医院每月定期实行人工逻辑交叉质控和重点质控来修正手术相关病案的编码缺陷。方法 通过一些逻辑规则,找出术科手术相关病案潜在编码缺陷并进一步核查修正,并结合PDCA持续性改进编码质量。结果 该措施实施一年以来,术科手术相关病案的编码缺陷率由原来的4.1%降低至2.5%(P=0.023),缺陷类型的分布不变(P=0.514),其中手术编码错误和遗漏是主要的错误类型,占全部缺陷的61.5%,应重点关注并改善。结论 采用人工逻辑交叉质控和重点质控,可及时有效发现潜在编码缺陷,为持续改进编码质量提供方向,值得进一步推广。Objective In order to improve the coding quality of international diseases and operations classification,a hospital regularly carries out cross quality control and key quality control monthly to correct the coding defects.Methods Through some logic rules,the potential coding defects of surgical related medical records were found and further checked and corrected,and the coding quality was continuously improved with PDCA method.Results One year after the implementation of this measure,the coding defect rate of surgical related medical records decreased from 4.1% to 2.5%(P=0.023),and the distribution of defect types remained unchanged(P=0.514).Among them,operation coding errors and omissions were the main error types,accounting for 61.5% of all defects,which should be focused on and improved.Conclusion Using of manual logic cross quality control and key quality control can find potential coding defects timely and effectively,provide the direction for continuous improvement of coding quality,and is worthy of further promotion.

关 键 词：疾病编码 手术编码 交叉质控 重点质控 

分 类 号：R197.323.1[医药卫生—卫生事业管理]