某市住院病案首页主要诊断和编码的质量分析  

Quality Control Analysis of Main Diagnosis and Coding on the Front Page of Hospitalized Medical Records in a City

作　　者：骆冰 郑艳平 何彩霞[1] Luo Bing;Zheng Yanping;He Caixia(Changsha Hospital Affiliated to Hunan Normal University,The Fourth Hospital of Changsha,Changsha 410006,Hunan Province,China)

机构地区：[1]湖南师范大学附属长沙医院长沙市第四医院,湖南省长沙市410006

出　　处：《中国病案》2023年第6期23-25,共3页Chinese Medical Record

摘　　要：目的 质控住院病案首页主要诊断和编码问题,分析不同问题产生的原因,探讨提升住院病案首页质量的方法。方法 选取某市二级及以上医疗机构2020年11月1日-2020年11月29日出院患者病案,按各医院医嘱系统显示的出院时间排序,三级医院抽取前50位,二级医院抽取前30位的住院病案首页721份,统计质控后错误率和缺陷情况。结果 721份病案中,临床医师主要诊断错误率为22.75%,编码员主要诊断编码错误率为7.63%。不同医院等级对比,医师和编码员错误率二级医院比三级医院高,差异有统计学意义,P<0.05。不同医院性质对比,医师和编码员错误率综合医院比专科医院高,差异有统计学意义,P<0.05。医师缺陷情况前三位分别是主要诊断不准确70.73%、肿瘤患者主要诊断选择错误10.37%和主要诊断与手术操作不一致10.37%;编码员缺陷情况前三位分别是主要诊断编码选择错误47.27%、未使用合并编码34.55%和疾病名称与编码不符14.55%。结论 该市住院病案首页主要诊断及编码质量问题不容乐观。主要是医师不能准确的填写主要诊断,编码员对ICD编码规则理解不透彻,且不同医院等级和性质的住院病案首页缺陷情况有差异。医院主管部门和临床医师应予以充分重视,构建持续有效的措施,从而提高住院病案首页质量。Objectives To make quality control on the front page mainly diagnoses and codes problems of inpatient medical records,analyze the causes of different problems,and investigate the methods to improve the quality of inpatient medical records front pages.Methods A total of 721 inpatient medical records of discharged patients from secondary and higher medical institutions in a city from November 1st to 29th,2020 were selected for statistical error rate and defect after quality control(According to the discharge time of each hospital medical order system,the top 50 hospitals were selected from the tertiary hospitals and the top 30 hospitals were selected from the secondary hospitals).Results In 721 discharged medical records,the main diagnostic error rate of clinicians was 22.75%,and the coder was 7.63%.Compared with different hospital grades,the error rates of physicians and coders in the secondary hospitals were higher than those in the tertiary hospitals,and the differences were statistically significant,P<0.05.Compared with the nature of different hospitals,the error rates of physicians and coders in general hospitals were higher than those in specialized hospitals,and the differences were statistically significant,P<0.05.The top three doctors'defects were inaccurate diagnosis(70.73%),incorrect choice of diagnosis(10.37%)and inconsistent diagnosis with surgical operation(10.37%).The top three coder'defects were mainly diagnostic code selection errors(47.27%),non-use of combined coding(34.55%),and inconsistent disease name and coding(14.55%).Conclusions The main diagnosis and coding quality problems of the front page of inpatient records in this city were not optimistic.The main reasons were that physicians could not accurately fill in the main diagnosis,coders did not have a thorough understanding of the ICD coding rules,and there were differences in the defects of the front page of inpatient medical records of different hospital grades and properties.Hospital authorities and clinicians should pay full attention to

关 键 词：主要诊断 住院病案首页 国际疾病分类 质量控制 

分 类 号：R197.323[医药卫生—卫生事业管理]