基于某院2378份住院病案首页的编码质量分析  

Analysis of Coding Quality Based on the Front Pages of 2378 Inpatient Medical Records from a Hospital

作　　者：王斌[1] 姬世兴 张敏 Wang Bin;Ji Shixing;Zhang Min(Department of Quality Control(Department of Medical Records and Statistics),Kunming First People's Hospital,Kunming 650011,Yunnan Province,China)

机构地区：[1]昆明市第一人民医院质控部(病案统计室),云南省昆明市650011

出　　处：《中国病案》2024年第4期1-4,共4页Chinese Medical Record

基　　金：昆明市卫生健康委员会卫生科研课题(2022-21-01-005)。

摘　　要：目的通过分析某院住院病案首页的编码质量了解编码现状,为提高疾病与手术操作编码质量提供参考。方法随机抽取某院2021年5月1日-2021年12月31日出院病案,由1名编码质控员对全院22个临床科室已编码病案进行住院病案首页质控,每月随机抽取约300份住院病案首页,一共抽取并质控了2378份住院病案首页。根据国家卫生健康委发布的《住院病案首页数据填写质量规范(暂行)》《住院病案首页数据质量管理与控制指标(2016版)》判断诊断与手术及操作选择正确与否;根据国际疾病分类(ICD-10)第一卷和第三卷、手术操作分类(ICD-9-CM-3)(2011版)中的编码原则判断编码正确与否,再根据质控结果生成的疾病编码评价表分析某院编码员的编码情况。结果质控的2378份住院病案首页中,无缺陷的1892份,有缺陷的486份,缺陷率为20.44%。在缺陷的486份病历中,主要诊断编码缺陷100份,其他诊断编码缺陷355份,主要手术及操作编码缺陷40份,其他手术及操作编码缺陷65份,分别占总缺陷份数的20.58%、73.05%、8.23%、13.37%。对有缺陷的486份病案进行仔细查阅,其中疾病诊断编码中缺陷最多的是多编码,占比28.13%,手术及操作后中编码缺陷最多的是遗漏编码,占比35.24%。结论出院诊断和手术及操作编码中,编码出现缺陷情况较多的问题是多编、编码中忽略病因、编码未细化以及漏编码等问题。Objectives By analyzing the coding quality of the front page of inpatient medical records in a hospital,we could understand the coding status quo and provide reference for improving the coding quality of diseases and surgical operations.Methods The discharged medical records of a hospital from May 1st,2021 to December 31st,2021 were randomly selected by a coded quality control officer.The code quality control officer conducted quality control on the front page of inpatient medical records in 22 clinical departments of the hospital,randomly selected about 300 front pages of inpatient medical records every month,and extracted and controlled a total of 2378 front pages of inpatient medical records.According to the National Health Commission issued"Inpatient Medical records front page data filling quality standards(interim)""Inpatient medical records front page data quality management and control indicators(2016 version)"to determine whether the diagnosis and surgery and operation selection was correct.According to the coding principles in the International Classification of Diseases(ICD-10)Volumes I and III,and the Classification of Surgical Operations(ICD-9-CM-3)(2011 edition),the coding situation of coders in a certain hospital was analyzed according to the disease coding evaluation table generated by the quality control results.Results Of the 2378 inpatient medical records of quality control,1892 were without defects and 486 were with defects,with a defect rate of 20.44%.Among the 486 medical records with defects,there were 100 defects in main diagnostic codes,355 defects in other diagnostic codes,40 defects in main surgical codes and 65 defects in other surgical codes,accounting for 20.58%,73.05%,8.23%and 13.37%of the total defects respectively.486 medical records with defects were carefully reviewed,and the specific types of defects of coders were summarized.Among them,multi-coding was the most defective in disease diagnosis coding,accounting for 28.13%,and missing coding was the most defective in surgery and o

关 键 词：住院病案首页 疾病编码 缺陷 编码员 

分 类 号：R197.323[医药卫生—卫生事业管理]