摘要
目的通过对2018年某院住院病案首页数据中的疾病和手术/操作编码进行回顾性质控,分析病案编码中常见错误的原因,提出可供参考的提高住院病案首页诊断和手术/操作准确率的措施。方法以某三甲医院2018年住院病案首页诊断及手术/操作专项督导检查每月所查DRGs未入组、低风险死亡组、CMI值离散度过大或过小、死亡病案共计1069份病案为研究对象,成立住院病案首页专项督导质控组,遵照国际疾病编码规则,采用双盲同行评议法,对样本进行质控。结果经质控,诊断与手术/操作全部正确病例占总样本量的60.34%;50个以上的样本量主要集中在疑难危重科室,其中重症监护室的样本量最高,占总样本量的17.21%;临床医师主要诊断、其他诊断、主要手术/操作、其他手术/操作正确率分别为77.46%、98.13%、80.92%、85.87%;编码员主要诊断、其他诊断、主要手术/操作、其他手术/操作正确率分别为94.20%、99.06%、85.50%、86.62%。结论开展住院病案首页诊断与手术/操作的全程多重质控即三级质控闭环模式,提高编码员知识储备,能提高临床医师和编码员对病案首页填写的责任心以及质量。
Objective Through the retrospective nature control of the disease surgery and operation codes on the front page of the medical records of a hospital in 2018,analyze the causes of common errors in medical record coding,puts forward some measures for reference to improve the accuracy of diagnosis and operation/operation on the first page of medical records.Methods Taking the medical records on the first page of the 2018 medical records and the special supervision and examination of surgery and operation on the first page of the medical records of a tertiary hospital in 2018 as the object of study,set up a special supervision and control group on the home page,carry out quality control of home page diagnosis surgery and operation on a monthly basis.Results After quality control,60.34% of the total samples were diagnosed and operated correctly,More than 50 samples are mainly collected in difficult and critical departments,The sample size of ICU is the highest,accounting for 17.21%of the total sample size;The correct rates of main diagnosis,other diagnosis,main surgery and operation and other surgery and operation were 77.46%,98.13%,80.92% and 85.87% respectively;The correct rates of main diagnosis,other diagnosis,main surgery and operation and other surgery and operation were 94.20%,99.06%,85.50% and 86.62% respectively.Conclusion To carry out the whole process of multi-quality control,that is,the closed-loop mode of three-level quality control,can improve the knowledge reserve of coders,and improve the responsibility and quality of clinicians and coders in filling out the home page of medical records.
作者
斯琴
刘才华
卢武红
Si Qin;Liu Caihua;Lu Wuhong(Medical Records Management Department,Medical Department,First Affiliated Hospital of Xinjiang Medical University,Wulumuqi 830000,Xinjiang Uygur Autonomous Region,China)
出处
《中国病案》
2020年第4期13-15,共3页
Chinese Medical Record
关键词
住院病案首页
诊断与手术操作
质控
改进思路
Home page of medical record
Diagnosis and operation
Quality control
Improving train of thought
