摘要
探究利用信息技术对病案首页编码准确率提升的作用.选择病案首页540份作为研究对象,研究开展时间2020年4月至2021年4月,无任何附加条件随机选取病案.2020年10月开始利用信息技术对病案首页编码进行校验,将2020年4月至2020年9月期间病案首页270份纳入对照组,未利用信息技术,2020年10月至2021年4月期间病案首页270份纳入试验组,利用信息技术.比较两组病案首页编码准确率,并分析病案首页编码常见错误类型.试验组病案首页编码准确率98.52%高于对照组95.56%,差异有统计学意义(P<0.05).病案首页编码常见错误包括不宜使用分类编码、性别与分类编码不相符、形态学编码缺失或错误、外因编码缺失、不能作主要诊断分类编码,其中不宜使用分类编码错误发生率最高.利用信息技术校验病案首页编码可以减少编码错误,使得病案首页数据质量提升,提高编码准确率,具有很高的应用价值.
To explore the role of information technology to improve the coding accuracy of home cases.540 disease cases on the home page were selected as the research subjects.The study was conducted from April 2020 to April 2021,and the disease cases were randomly selected without any additional conditions.In October 2020,information technology began to check the home page of the cases,and 270 copies of the home page from April 2020 to September 2020 were included in the control group,and information technology was unused.From October 2020 to April 2021,270 copies were included in the test group,and information technology was used.Comparing the accuracy of the home page coding of the two groups of disease cases,and analyzing the common error types of the home page coding.The coding accuracy in the test group was 98.52%,higher than 95.56%in the control group,and the difference was significant(P<0.05).Common errors in coding on the home page of disease cases include the unuse to the classification code,gender inconsistent with the classification code,morphological code lack or error,external code inability to make the main diagnostic classification code,among which the incidence of classification coding error is the highest.Using information technology to check the home page coding of disease cases can reduce the coding error,improve the data quality,improve the coding accuracy,and have high application value.
作者
陈健玲
CHEN Jian-ling(Yulin Second People's Hospital,Guangxi Yulin 537000,China)
出处
《新一代信息技术》
2022年第7期24-27,共4页
New Generation of Information Technology
关键词
病案首页
编码
信息技术
编码错误
case home page
coding
information technology
coding error
