病案信息技术对病案室编码及病案质量的影响  

Influence of Medical Record Information Technology on Medical Record Room Coding and Medical Record Quality

作　　者：王芳 WANG Fang(Medical Records Room,Fuzhou Neuro-psychiatric Hospital,Fujian Province,Fuzhou Fujian 350000,China)

机构地区：[1]福建省福州神经精神病防治院病案室,福建福州350000

出　　处：《中国卫生标准管理》2023年第3期10-13,共4页China Health Standard Management

摘　　要：目的探究采取病案信息技术对病案室编码及病案质量的影响。方法回顾性分析2020年3月—2022年2月福建省福州神经精神病防治院病案室2600例病案的相关数据。其中2020年3月—2021年2月为干预前,共1300例病案;2021年3月—2022年2月为基于病案信息技术干预后,共1300例病案。对每份病案进行疾病分类编码审核,比较干预前后病案室编码准确率及病案质量评分。结果干预后,病案室编码准确率为90.69%,高于干预前的70.77%,差异有统计学意义(P<0.05);干预后的各项病案管理质量评分较干预前更高,差异有统计学意义(P<0.05)。结论为提升病案室编码准确率及病案质量评分,选择应用基于病案信息技术的影响效果明显,值得在医院病案室推广应用。Objective To explore the impact of adopting medical record information technology on the coding of medical record room and the quality of medical record.Methods The data of 2600 medical records in room of medical record,Fuzhou Neuro-psychiatric Hospital,Fujian Province from March 2020to February 2022 were analyzed retrospectively.From March 2020 to February 2021,there were 1300 medical records before the intervention.From March 2021 to February 2022,there were 1300 medical records based on medical record information technology.The disease classification and coding of each medical record were reviewed,and the coding accuracy of the medical record room before and after the intervention was compared,as well as the quality score of the medical record before and after the intervention.Results After intervention,the coding accuracy of medical record room was 90.69%,higher than 70.77%before intervention,the difference was statistically significant(P<0.05).The scores of medical record management quality after intervention were higher than those before intervention,and the differences were statistically significant(P<0.05).Conclusion In order to improve the coding accuracy of the medical record room and the quality score of the medical record,the selection and application of medical record information technology has obvious effects,which is worth popularizing in the medical record room of the hospital.

关 键 词：病案室编码 疾病分类编码 准确率 病案信息技术 医院病案室 病案质量评分 

分 类 号：R197[医药卫生—卫生事业管理]