病案书写质量对疾病编码的影响分析  

Analysis of the influence of medical record writing quality on disease coding

作　　者：崔晓朦 王丽莉[1] CUI Xiao-meng;WANG Li-li(Department of Medical Administration,Tianjin Staff Hospital,Tianjin 300050,.China)

机构地区：[1]天津市职工医院医政科,天津300050

出　　处：《中国城乡企业卫生》2022年第11期65-67,共3页Chinese Journal of Urban and Rural Enterprise Hygiene

摘　　要：目的分析病案书写质量对疾病编码的影响,以提高疾病编码正确率。方法回顾性分析2020年1月—2021年1月天津市职工医院因病案书写质量问题导致疾病编码错误的63份案例,基于归类分析法对问题类型进行划分,分析病案书写质量对疾病编码的影响、病案书写质量问题发生原因及提高病案书写质量策略。结果病案书写质量问题共涉及病案首页疾病诊断名称书写不规范、主要诊断选择不准确、次要诊断漏写、病历漏签字等。结论病案书写质量问题的出现直接导致疾病编码错误,无法客观反馈患者病情变化与临床诊治过程。对付款疾病分组、院内准确统计、病历资料检索都将产生直接的影响,而从发生病案书写质量问题的原因来看,人为因素占主导。因此,应对病案书写人员进行严格要求与管理,引导其利用计算机应用软件书写病案、做好岗前培训,严格落实管理、检查工作,并利用奖惩机制强化工作人员责任及质量意识,从而提高疾病编码的准确性。Objective To analyze the influence of medical record writing quality on disease coding,so as to improve the correct rate of disease coding.Methods A total of 63 cases of error disease coding caused by the quality problems of medical record writing in Tianjin Staff Hospital from January 2020 to January 2021were retrospectively analyzed.The problem types were classified based on the classification analysis method,and the influence of the quality of medical record writing on the disease coding,the causes of the quality problems of medical record writing,and the strategies to improve the quality of medical record writing were analyzed.Results The quality problems of medical record writing involved nonstandard writing of disease diagnosis name on the first page of medical record,inaccurate selection of main diagnosis,omission of secondary diagnosis,omission of signature of medical record and so on.Conclusion The occurrence of the quality problem of medical record writing directly leaded to the error of disease coding,and it was impossible to objectively give feedback on the changes of patients’condition and the process of clinical diagnosis and treatment,which would have a direct impact on the grouping of payment diseases,accurate statistics in the hospital and case data retrieval.However,from the causes of the quality problem of medical record writing,human factors were dominant.Therefore,strict requirements and management should be carried out for medical record writers to guide them to use computer application software to write medical records,do a good job of pre job training,strictly implement management and inspection,and strengthen staff’s responsibility and quality awareness by using reward and punishment mechanism,so as to improve the accuracy of disease coding.

关 键 词：病案书写 书写质量 疾病编码 

分 类 号：R197.323[医药卫生—卫生事业管理]