公立医院病案首页主要诊断编码正确率影响因素分析  

Analysis of factors influencing the correct coding rate of major diagnoses on the first page of medical cases in public hospitals

作　　者：杨松航 刘新奎[2] 田庆丰[1] 尚小平[2] 杨林朋[2] 和小女 YANG Songhang;LIU Xinkui;TIAN Qingfeng;SHANG Xiaoping;YANG Linpeng;HE Xiaonv(School of Public Health,Zhengzhou University,Zhengzhou 450000,China;The First Affiliated Hospital of Zhengzhou University,Zhengzhou 450000,China)

机构地区：[1]郑州大学公共卫生学院,河南郑州450000 [2]郑州大学第一附属医院,河南郑州450000

出　　处：《现代医院》2023年第6期885-889,共5页Modern Hospitals

基　　金：河南省医学科技攻关计划软科学项目(RKX202202009,RKX202202030)。

摘　　要：目的探究河南省二级以上公立医院住院病案首页主要诊断编码正确率状况及影响因素,为提高主要诊断编码正确率,提升病案管理质量提供参考。方法对河南省参与2020年绩效考核的二级及以上公立医院病案科采取问卷调查获得病案科基本情况和人员信息并随机抽取2020年11月出院的200份病案调查其主要诊断编码状况,采用独立样本t检验、方差分析来比较主要诊断编码正确率在各指标的不同分组状态下是否存在差异,并且采用因子分析和多重线性回归分析来探究其影响因素。结果编码人员配置(t=2.503,P=0.013)、编码员工作负担(t=-3.604,P<0.001)和医院类别(t=1.475,P<0.001)是主要诊断编码正确率的影响因素(P<0.05)。病案科对外业务、病案科编码病案类型、病案编码、统计和供应工作、病案归档和质控工作不会对主要诊断编码正确率产生影响。结论增加病案编码人员数量,优化编码人员配置,增强编码员整体素质有利于提升住院病案主要诊断病案编码质量,提高病案管理水平。Objective To explore the correct rate of main diagnostic codes on the first page of inpatient medical records of public hospitals above the second level in Henan Province and its influencing factors,so as to provide reference for improving the correct rate of main diagnostic codes and the quality of medical record management.Methods The medical record department of the second level and above public hospitals in Henan Province participating in the 2020 performance appraisal obtained the basic information and personnel information of the medical record department through the questionnaire survey,and randomly selected 200 medical records discharged in November 2020 to investigate the status of their main diagnostic codes.The independent sample t-test and square error analysis were used to compare whether the accuracy of the main diagnostic codes were different under different grouping states of each indicator,Factor analysis and multiple linear regression analysis were used to explore the influencing factors.Results Coder allocation(t=2.503,P=0.013),coder workload(t=-3.604,P<0.001)and hospital category(t=1.475,P<0.001)are the influencing factors(P<0.05)for the accuracy of main diagnostic codes.The external business of the medical record department,the type of medical records coded by the medical record department,the coding,statistics and supply of medical records,and the archiving and quality control of medical records will not affect the accuracy of main diagnostic codes.Conclusion Increasing the number of medical record coding personnel,optimizing the coding personnel configuration,and enhancing the overall quality of the coding personnel are conducive to improving the coding quality of the main diagnosis medical records of inpatient medical records and improving the medical record management level.

关 键 词：病案管理 病案科 主要诊断编码 因子分析 

分 类 号：R197.323.1[医药卫生—卫生事业管理]