某三甲综合医院3316份住院病案首页主要诊断编码质量分析  

Analysis of Main Diagnosis Coding Quality on the Front Page of 3316 Medical Records in Grade A Tertiary General Hospital

作　　者：许慧娜[1,2] 吴玉连 黄月凤[1,2] 侯毅翰 陈丽君[1] XU Huina;WU Yulian;HUANG Yuefeng;HOU Yihan;CHEN Lijun(Medical Records Office,the First Affiliated Hospital of Xiamen University,Xiamen Fujian 361000,China;the Quality Control Center of Xiamen Medical Record Management,Xiamen Fujian 361000,China)

机构地区：[1]厦门大学附属第一医院病案办公室,福建厦门361000 [2]厦门市病案管理质量控制中心,福建厦门361000

出　　处：《中国卫生标准管理》2024年第18期5-8,共4页China Health Standard Management

摘　　要：目的分析厦门市某三甲综合医院2023年1—12月住院病案首页主要诊断编码质量,分析编码错误原因,提出有效的改进建议,以期提高医院住院病案首页主要诊断编码质量。方法采用分层抽样选取厦门市某三甲综合医院2023年1—12月住院病案3316份,由科室9名编码员对抽取的病案首页进行交叉互查,登记编码错误类型,分析编码错误原因。结果主要诊断编码错误353份,主诊编码错误率为10.65%。对错误类型归类:未认真分析病历资料占比48.44%,未掌握主要诊断编码原则占比27.48%,临床知识不足占比14.16%,系统获取错误占比9.92%。结论注重病案编码专业人才队伍的建设,培养编码员的工作能力,推进病案管理系统改进和优化,有利于持续优化病案首页主要诊断编码质量。Objective To analyze the quality of main diagnosis coding on the first page of inpatient medical records from January to December 2023 in grade A tertiary general hospital in Xiamen City,analyze the causes of coding errors,and put forward effective improvement suggestions to improve the quality of main diagnosis coding on the first page of inpatient medical records in the hospital.Methods Stratified sampling was employed to select 3316 inpatient medical records from from January to December 2023 in grade A tertiary general hospital in Xiamen City.A total of 9 coders from the department conducted cross-checks on the selected medical records,recording the types of coding errors and analyzing the reasons for these errors.Results There were 353 errors in the major diagnosis codes,resulting in a main diagnosis coding error rate of 10.65%.The errors were categorized as follows:inadequate analysis of medical records(48.44%),lack of understanding of main diagnosis coding principles(27.48%),insufficient clinical knowledge(14.16%),and system retrieval errors(9.92%).Conclusion Pay attention to the construction of medical record coding professional personnel,train the working ability of coders,and promote the improvement and optimization of medical record management system,which is conducive to the continuous optimization of the quality of the main diagnosis coding of medical records.

关 键 词：病案首页 主要诊断编码 质量分析 编码错误类型 病案管理改进 专业人才培养 

分 类 号：R197[医药卫生—卫生事业管理]