某院1000份住院病案首页ICD编码质量分析  

Quality Analysis on the ICD coding of the Front Page of 1000 Inpatient Medical Records in a Hospital

作　　者：胡亚 肖三麦 郑颖 Hu Ya;Xiao Sanmai;Zheng Ying(Department of Inpatient and Case Management,The Fourth Medical Center,Chinese People's Liberation Army General Hospital,Beijing 100048,China;不详)

机构地区：[1]中国人民解放军总医院第四医学中心门诊部住院与病案管理科,北京市100048

出　　处：《中国病案》2024年第6期17-19,共3页Chinese Medical Record

摘　　要：目的 通过调查某市三级医院住院病案首页ICD编码存在的问题,以期为提高住院病案首页数据质量寻找有效地改进措施。方法 采取分层随机抽样的方法抽取某市三级医院2023年1月1日-2023年6月30日共1000份出院病案,根据国家疾病分类与代码应用指导手册中关于疾病诊断和手术操作的填报要求,对抽取的病案重新核查诊断和手术操作,采用三级质控法,利用Microsoft OfficeExcel2013表格详细记录各科室ICD编码错误情况,统计编码错误的类别分布。结果 通过对1000份住院病案首页进行核查,编码错误病案215份,编码错误率为21.5%。主要诊断错误例数93份(63.70%),其他诊断错误例数53份(36.30%);主要手术/操作错误例数51份(73.91%),其他诊断错误例数18份(26.09%)。结论 ICD编码质量与临床医师的书写和编码员的专业水平有关,应从提升编码员综合技能和临床医师相关培训以及建立有效的沟通入手,持续提高ICD编码准确率。Objectives To investigate the problems in the ICD coding of the front page of medical records in a tertiary hospital in a certain city,in order to find effective improvement measures to improve the quality of data on the front page of inpatient medical records.Methods A total of 1000 discharged medical records from a tertiary hospital in a city were selected by stratified random sampling method from January 1st,2023 to June 30th,2023.According to the filling requirements of disease diagnosis and surgical operation in the national Disease Classification and Code application guidance manual,the diagnosis and surgical operation of the extracted medical records were re-checked and the tertiary quality control method was adopted.Microsoft Office Excel 2013 tables were used to record the ICD coding errors of each department in detail,and the category distribution of coding errors was counted.Results As a result,from January 1st to June 30th,2023,there were 23147 inpatient medical records on the front page.Out of 7%,1000 inpatient medical records were selected as the subjects for examination.After checking the front pages of 1000 inpatient medical records,215 were incorrectly coded,with a coding error rate of 21.5%.The number of main diagnostic errors was 93(63.70%),while the number of other diagnostic errors was 53(36.30%);There were 51 cases of major surgical/operational errors(73.91%),and 18 cases of other diagnostic errors(26.09%).Conclusions The quality of ICD coding was related to the writing of clinicians and the professional level of coders.We should improve the comprehensive skills of coders and relevant training of clinicians and establish effective communication to continuously improve the accuracy of ICD coding.

关 键 词：住院病案首页 ICD 编码质量 分析 

分 类 号：R197.323[医药卫生—卫生事业管理]