摘要
目的分析疾病分类和手术操作分类的常见错误,以提高疾病分类和手术分类质量。方法采用某三甲医院2013年5月-2014年4月每月抽查病案80份,进行疾病和手术分类编码检查,分析错误原因。结果共抽取病案960份,发现问题病案92份。其中涉及疾病分类编码错误的58份,错误率为6.0%。涉及手术操作分类错误的34份,错误率为3.5%。结论编码错误原因与编码员责任心不足,阅读病案不细致,以及对疾病认识不足、对疾病分类的原则掌握不够有关。科室质量小组的常态检查是提高编码质量的有效措施。
Objective To analysis the common errors in classification of diseases and operation, and to improve the quality of classification. Methods Selecting 80 medical records a month during May 2013 and April 2014, and checking the classification of disease and operation, analyzing error causes. Results There were 92 defect medical records in a total of 960 medical records. 58 medical records had disease classification coding errors, the error rate was 6%. 34 medical records had operation classification coding errors, the error rate was 3.5%. Conclusion Coding error related to coder lack of sense of responsibility, reading medical record is not careful and insufficient understanding of disease and the principle of classification of diseases. Normal inspection of the department quality team is an effective measure to improve the quality of coding.
出处
《中国病案》
2014年第12期22-23,共2页
Chinese Medical Record
关键词
国际疾病分类
手术操作分类
质量分析
International Classification of Diseases
Classification of surgical operation
Quality analysis
