人工交叉质控在病案编码中的实践效果  

Practical Effect of Manual Cross Quality Control in Medical Record Coding

作　　者：庄睿萱 ZHUANG Rui-xuan(Department of Quality Control,Women and Children's Hospital,School of Medicine,Xiamen University,Xiamen 361003,Fujian,China)

机构地区：[1]厦门大学附属妇女儿童医院/厦门市妇幼保健院质量管理部,福建厦门361003

出　　处：《医学信息》2024年第11期63-68,共6页Journal of Medical Information

摘　　要：目的 探讨某三甲专科医院实行的人工交叉质控病案编码模式在病案编码中的可行性。方法 抽取某三甲专科医院2021年2月-12月(共10 783份)与2022年2月-12月(共38 133份)病案管理软件中的住院病案资料,2021年2月-12月仅采用终末质控方法,2022年2月-12月进行终末质控和人工交叉质控。比较两段时期内病案资料的主要诊断选择正确率、主要诊断编码正确率、主要手术选择正确率及主要手术编码正确率。结果 2022年2月-12月终末质控后病案资料的主要诊断选择正确率、主要诊断编码正确率、主要手术选择正确率及主要手术编码正确率均略低于2021年2月-12月,其中主要手术选择正确率和主要手术编码正确率比较,差异有统计学意义(P<0.05)。2022年2月-12月终末质控后病案资料的主要诊断选择正确率、主要诊断编码正确率、主要手术选择正确率及主要手术编码正确率均低于人工交叉质控,差异有统计学意义(P<0.05)。2022年2月-12月两轮质控后,除了病案资料主要手术编码正确率略低于2021年2月-12月,其余三项均高于2021年2月-12月,但差异无统计学意义(P>0.05)。结论 人工交叉质控可提高病案资料的编码准确率,虽然人工交叉质控并未体现出较大的优势,但可能和该院原本编码质量较高,提升空间少,以及人员变动有关。实行人工交叉质控病案编码模式使该三甲专科医院避免了因人员变动导致编码质量大幅下降,该模式值得医院探索与实践。Objective To explore the feasibility of manual cross quality control medical record coding mode in medical record coding in a tertiary hospital.Methods The inpatient medical record data in the medical record management software of a tertiary specialized hospital from February to December 2021(a total of 10783 copies)and February to December 2022(a total of 38133 copies)were extracted.From February to December 2021,only the final quality control method was used.From February to December 2022,the final quality control and the manual cross quality control were carried out.The correct rate of main diagnosis selection,the correct rate of main diagnosis coding,the correct rate of main operation selection and the correct rate of main operation coding were compared between the two periods.Results The correct rate of main diagnostic selection,the correct rate of main diagnostic coding,the correct rate of main surgical selection and the correct rate of main surgical coding of medical record data after final quality control from February to December 2022 were slightly lower than those from February to December 2021,among which the correct rate of main surgical selection and the correct rate of main surgical coding were compared,and the differences were statistically significant(P<0.05).From February to December 2022,the correct rate of main diagnosis selection,the correct rate of main diagnosis coding,the correct rate of main operation selection and the correct rate of main operation coding of medical record data after final quality control were lower than those of manual cross quality control,and the differences were statistically significant(P<0.05).After two rounds of quality control from February to December 2022,except that the correct rate of main surgical coding of medical record data was slightly lower than that from February to December 2021,the other three were higher than those from February to December 2021,but the difference was not statistically significant(P>0.05).Conclusion Manual cross quality control can i

关 键 词：病案编码 人工交叉质控 终末质控 管理质量 

分 类 号：R197[医药卫生—卫生事业管理]