摘要
目的分析外科病案首页诊断及手术与操作数据质量,提出改进措施。方法选择某三甲综合医院2016年外科住院病案首页500份,对首页中的诊断、手术与操作名称及相应编码的正确性进行评价。结果500份首页主要诊断名称填写正确率为77. 80%,主要诊断编码正确率为80. 20%;其他诊断名称填写正确率为76. 74%,其他诊断编码正确率为78. 02%;主要手术操作名称填写正确率为81. 20%,主要手术操作编码正确率为83. 20%;其他手术操作名称填写正确率为80. 05%,其他手术操作编码正确率为83. 59%。结论外科病案首页诊断及手术与操作数据质量仍需提高,加强临床医师对诊断及手术与操作名称填写质量控制、提高编码员水平是改进数据质量的有效措施。
Objective:To analyze the first page diagnosis,the quality of operation and the operation data,and put forward the improvement measures.Method:The first 500 surgical inpatient records of a comprehensive hospital of Class A and Grade Three in 2016 were selected.The correctness of the diagnosis,the operation,operation names and the corresponding codes on the first page was evaluated.Result:The correct rate of filling out the main diagnostic names on the first page of 500 records was 77.80%,and the correct rate of the main diagnostic codes was 80.20%.The completion rate of other diagnostic names was 76.74%and that of other diagnostic codes was 78.02%.The correct rate of filling in major operation names was 81.20%,and the correct rate of coding of major operation was 83.20%.The correct rate of filling in other operation names was 80.05%,and that of coding for other operation was 83.59%.Conclusion:The first page of surgical record diagnosis,and the quality of surgical and operational data still need to be improved.It is an effective measure to improve the data quality so as to strengthen the quality control of diagnosis,operation and operation name filling,and improve the coder level.
作者
张慧利
张连军
周云
黄春燕
ZHANG Hui-li;ZHANG Lian-jun;ZHOU Yun;HUANG Chun-yan(The First Affiliated Hospital of Nanchang University,Nanchang 330006,China)
出处
《现代医院管理》
2018年第6期30-32,共3页
Modern Hospital Management
关键词
外科病案首页
诊断
手术操作
数据质量
the first page of surgical record
diagnosis
surgical operation
data quality