诊断-编码映射模式在肿瘤专业病案编码工作中的应用效果  

Application Effect of Diagnosis Coding Mapping Mode in Medical Record Coding of Oncology Specialty

作　　者：王晶晶[1] 赵慧智[1] 王卫卫[1] 张红敏[1] 王坤锐 Wang Jingjing;Zhao Huizhi;Wang Weiwei;Zhang Hongmin;Wang Kunru(Hebei Provincial People's Hospital,Shijiazhuang 050051,Hebei Province,China;不详)

机构地区：[1]河北省人民医院,河北省石家庄市050051

出　　处：《中国病案》2023年第2期10-12,共3页Chinese Medical Record

基　　金：河北省2019年度医学科学研究重点课题计划(20190212)。

摘　　要：目的 评价应用诊断-编码映射模式,对提高肿瘤专业病案首页质量及减轻编码员负担的效果。方法 提取某三级综合医院2018年6月1日至2018年6月30日、2020年6月1日至2020年6月30日的肿瘤专业住院病案首页数据,将通过诊断-编码映射关系生成的临床诊断编码与人工审核后的ICD编码进行对比。结果 应用诊断-编码映射模式后,系统均可按照医师选择诊断名称自动生成诊断-编码映射关系相应的临床诊断编码,2020年的诊断编码映射率达100.0%,较2018年提升了11.2%。编码员的工作模式从“逐条编码”转变为“逐条审核”,肿瘤专业的诊断编码一致率由60.2%提升至85.6%,前三位收治病种的主要诊断编码一致率由0.0%提升至100.0%。结论 通过应用诊断-编码映射模式,优化了疾病诊断的书写与编码工作流程,规范了医师的疾病诊断书写习惯,使疾病编码更加准确,同时减轻编码员负担,提高编码工作效率,从而提升了住院病案首页编码质量。Objectives To evaluate the effect of applying the diagnosis coding mapping mode on improving the quality of the front page of medical records of oncology specialty and reducing the burden of coders. Methods The front page’ data of oncology medical records of a Three A and Tertiary General Hospital from June 1st, 2018 to June 30th, 2018 and from June 1st, 2020 to June 30th, 2020 were extracted, and the clinical diagnosis code generated by diagnosis-coding mapping relationship was compared with the ICD code after manual review. Results After applying the diagnosis-coding mapping mode, the system could automatically generate the clinical diagnosis code corresponding to the diagnosis-coding mapping relationship according to the diagnosis name selected by the doctor.The working mode of coders had changed from "code-by-line" to "check-by-line", the consistency rate of diagnostic codes for the oncology specialty had increased from 60.2% to 85.6%, and the consistency rate of the main diagnostic codes of the top three treated diseases had increased from 0.0% to 100.0%. Conclusions Through applying the diagnosis coding mapping mode, the writing and coding workflow of disease diagnosis was optimized,not only the oncologist’s diagnosis writing were regulated, the coding accuracy was raised, at the same time, the workload of coder was also reduced, the coding efficiency was enhanced, thereby the quality of the front page of medical records was improved.

关 键 词：肿瘤专业 ICD-10编码 临床诊断 质量控制 

分 类 号：R197.5[医药卫生—卫生事业管理]