三级编码质控能够有效增加编码正确率  

Three-level Coding Quality Control Can Effectively Increase Coding Accuracy

作　　者：李晓鹏 殷小磊 李伟静 张彬[1] 黄金丽 陈宁 李书梅[1] Li Xiaopeng;Yin Xiaolei;Li Weijing;Zhang Bin;Huang Jinli;Chen Ning;Li Shumei(Department of Medical Records,The Fourth Hospital of Hebei Medical University,Shijiazhuang 050011,Hebei Province,China;不详)

机构地区：[1]河北医科大学第四医院病案科,河北省石家庄市050011 [2]河北医科大学第四医院消化内科,河北省石家庄市050011

出　　处：《中国病案》2024年第7期9-12,共4页Chinese Medical Record

基　　金：河北省医学科学研究重点课题(20230820)。

摘　　要：目的探讨编码质控管理在某三甲医院ICD编码准确性中的应用效果,逐步提高编码质量。方法抽取某三甲医院2022年1月1日-2022年6月30日实施编码质控管理前的病案720份为对照组,抽取2023年1月1日-2023年6月30日实施编码质控管理后的病案720份为观察组。分别对这两组病案的诊断编码、手术编码准确性和完整性进行质控。统计编码准确率,分析错误编码原因,并制定改进措施。结果对照组中编码正确584例,正确率81.11%;观察组中编码正确671例,正确率93.19%,两组结果分析差异有统计学意义。编码错误类型主要有主要手术操作编码选择错误、主要诊断编码选择错误、病理诊断编码错误或与诊断编码不匹配、未按规则进行合并编码及另编码等。通过实施编码质控管理后,编码总体错误率由18.89%降低至6.81%。结论编码质控管理方法能够显著提高ICD编码的准确率,改进住院病案首页质量,促进医院医疗质量的提升。Objectives This study aims to explore the application effect of coding quality control management on ICD coding accuracy in a tertiary hospital,so as to improve the coding quality.Methods A total of 720 medical records from a tertiary hospital before implementation of coding quality control management from January 1,2022 to June 30,2022 were selected as the control group,while another 720 medical records after implementation of coding quality control management from January 1,2023 to June 30,2023 were selected as the observation group.The accuracy and completeness of the diagnostic and surgical codes in the medical records of these two groups were assessed.Coding accuracy was calculated,the causes of coding errors were analyzed,and improvement measures were formulated.Results In the control group,584 cases were correctly coded,with an accuracy rate of 81.11%.In the observation group,671 cases were correctly coded,with a correct rate of 93.19%.The difference between the two groups was statistically significant.The main types of coding errors included errors in coding selection for major surgical operations,errors in coding selection for major diagnoses,errors in pathological diagnosis coding or mismatch with diagnostic coding,and failure to perform merge coding and separate coding according to rules.After the implementation of coding quality control management,the overall coding error rate was reduced from 18.89%to 6.81%.Conclusions The coding quality control management method can effectively improve the accuracy of ICD coding,improve the quality of the first page of medical records,and promote the improvement of medical quality in hospitals.

关 键 词：编码质控管理 ICD编码 准确性 错误分析 

分 类 号：R197.323[医药卫生—卫生事业管理]