构建模块化ICD和手术操作分类工作对病案信息管理的影响  

Effect of Modular ICD and Surgical Operation Classification on Medical Record Information Management

作　　者：钟佩尧 张旻旻 谢妙玲 宁雪雄 ZHONG Peiyao;ZHANG Minmin;XIE Miaoling;NING Xuexiong(Dongguan Songshan Lake Central Hospital,Dongguan,Guangdong 523320)

机构地区：[1]东莞市松山湖中心医院,广东东莞523320

出　　处：《智慧健康》2024年第35期8-11,共4页Smart Healthcare

摘　　要：目的探讨在病案信息管理中构建模块化国际疾病分类(ICD)和手术操作分类工作系统对管理工作的影响。方法选择病案室构建并应用模块化ICD和手术操作分类工作前后时间节点进行研究,2023年2—4月存入的1622份病案信息作为应用前,2023年11月—2024年1月存入的1648份病案信息作为应用后。针对应用前后的病案信息编码错误发生情况、不同入院情况者的病案信息管理效率、管理工作人员满意率情况进行对比。结果构建模块化ICD和手术操作分类工作系统后,病案信息诊断编码错误、合并编码错误、手术分类与操作编码错误总发生率低于应用前(P<0.05)。应用后,病案管理工作人员针对初次、二次、多次入院的病例,在病案管理时间上明显比应用前更短(P<0.05)。应用后,病案信息管理工作人员对于分类工作系统应用总满意率明显比应用前高(P<0.05)。结论在医院病案信息管理工作中,构建模块化的ICD和手术操作分类系统,能够明显降低病案信息编码错误发生率,提高病案信息管理效率及提高管理人员的满意率,值得推广。Objective To explore the effect of constructing modular International Classification of Diseases(ICD)and surgical operation classification system on medical record information management.Methods The paper chose time nodes before and after construction and application of modular ICD and surgical operation classification in medical record room for study.1622 medical records stored from February to April 2023 were included in before application group,and 1648 medical records stored from November 2023 to January 2024 in after application group.Incidence of coding errors in medical record information before and after application,management efficiency of medical record information for patients with different admission situations and satisfaction degree of management staff was compared.Results After application,total incidence of diagnostic coding errors,merge coding errors,surgical classification and operation coding errors was during medical record management,that before application was,with statistical significance,(P<0.05).After application,medical record management time for first-time,second time and multiple hospitalized cases of medical record management staff was significantly shorter,difference before and after was statistically significant(P<0.05).Overall satisfaction degree of medical record information management staff with classification work system application after application was significantly higher than before application,difference before and after was statistically significant(P<0.05).Conclusion During medical record information management of hospitals,modular ICD and surgical operation classification system can reduce incidence of coding errors in medical record information significantly,improve efficiency of medical record information management and increase satisfaction degree of management staff,which is worthy of promotion.

关 键 词：病案信息管理 模块化 国际疾病分类 手术操作分类 

分 类 号：TP3[自动化与计算机技术—计算机科学与技术]