基于督导检查结果分析某院住院病案首页质量  

Analysis of the Quality of the Front page of Inpatient Medical Records Based on Supervisory Inspection Results at a Selected Hospital

作　　者：张剑非 Zhang Jianfei(Civil Aviation General Hospital,Beijing 100123,China)

机构地区：[1]民航总医院,北京市100123

出　　处：《中国病案》2024年第5期28-29,97,共3页Chinese Medical Record

摘　　要：目的分析某院住院病案首页数据填报质量督导检查反馈情况,提升医院住院病案首页数据填报质量。方法北京市卫生健康大数据与政策研究中心组织临床和编码专家,采用精准定位疑似问题抽样法,抽查某院2020年1月1日-2021年12月31日住院病案200份,对督导检查的反馈结果,由质控医师和编码员逐条核对,采用Excel2013进行统计分析。结果200份督导检查的病例中缺陷病例145份,占比72.5%,其中主要诊断及编码错误的病例数50份,占比25%;主要手术操作填写及编码错误的病例数20份,占比10%。其中医师方面:主要诊断填写错误为45例,主要手术填写错误为10例,其它诊断填写错误为57例,其它手术及操作填写错误为38例。编码方面:主要诊断编码错误为5例,主要手术错误为10例,其他诊断编码错误为17例,其它手术错误为3例。结论住院病案首页数据填报质量有待提高,主要原因是医师不能准确的填写诊断与手术操作。医院应定期对临床医师进行住院病案首页填写规范化培训,提升编码员综合能力,以提高住院病案首页质量,为DRG和三级公立医院绩效考核提供真实可靠的数据。Objectives This study aims to analyze the feedback from the quality supervision inspection on the front page of the inpatient medical records of a certain hospital,so as to improve the quality of data filling on the front page of hospital inpatient medical records.Methods The Beijing Municipal Health and Big Data Policy Research Center organized clinical and coding experts to randomly check 200 inpatient medical records in a certain hospital from January 1,2020 to December 31,2021,using a precise positioning method for suspect problem sampling.The feedback results of the supervision inspection were checked item by item by quality control physicians and coders,and Excel 2013 was used for statistical analysis.Results Among the 200 cases inspected by supervision,there were 145 defective cases,accounting for 72.5%,of which 50 cases had main diagnosis and coding errors,accounting for 25%.The number of cases with incorrect filling and coding of major surgical operations was 20,accounting for 10%.In terms of physicians,there were 45 cases of errors in filling in main diagnoses,10 cases of errors in filling in major surgeries,57 cases of errors in filling in other diagnoses,and 38 cases of errors in filling in other surgeries and operations.In terms of coding,there were 5 major diagnosis coding errors,10 major surgical errors,17 other diagnostic coding errors,and 3 other surgical errors.Conclusions The quality of initial inpatient medical record data reporting at the selected hospital is concerning,primarily due to physicians'inaccurate documentation of diagnoses and surgical procedures.Hospitals should regularly train clinical physicians in standardized documentation of inpatient medical records and enhance the comprehensive clinical thinking of coders to improve the quality of initial inpatient medical records.This is crucial for providing reliable data for DRG and performance assessment in tertiary public hospitals.

关 键 词：住院病案首页 编码 诊断 手术 操作 

分 类 号：R197.323[医药卫生—卫生事业管理]