摘要
目的了解根本死因不规范编码报告的原因,探讨降低不规范编码报告的有效方法。方法对北京市某区医疗机构2020年6月1日-2021年5月31日上报死亡个案信息中201例根本死因不规范编码进行复核,通过调阅病案及家属访谈的方式了解死亡患者生前病史、疾病诊疗情况及临终前的症状及体征,综合判断死亡患者的直接死亡原因,推导出死因链及根本死因,将数据导入SPSS19.0进行统计,分析复核前后根本死因编码的变化情况。结果追溯出可替代不规范编码的根本死因112例,其中心脑血管疾病51例,损伤中毒13例,恶性肿瘤12例,呼吸系统疾病9例,内分泌营养代谢疾病7例,肌肉骨骼和结缔组织疾病6例,精神和行为障碍5例,消化系统疾病、传染病各3例,皮肤病2例,先天疾病1例。复核后剩余不规范死因共89例,较前减少了55.72%。结论死因链追溯不完整是导致根本死因不规范编码的主要原因,加强临床医师的培训,提高死因链填写完整性是减少根本死因不规范编码的主要方法。
Objectives This study aims to Understand the reasons for non-standard coded reports of the underlying cause of death and explore effective methods to reduce non-standard coded reports.Methods 201 non-standard codes of underlying causes of death reported by medical institutions in a certain district of Beijing from June 1,2020 to May 31,2021 were reviewed.By consulting medical records and family interviews,this study understood the medical history,disease diagnosis and treatment,and symptoms and signs of the deceased patients before death,comprehensively judged the direct cause of death of the deceased patients,deduced the cause of death chain and the root cause of death,and imported the data into SPSS19.0.The changes in the underlying cause of death codes before and after the review were summarized and analyzed.Results 112 cases of the root cause of death that could be replaced by non-standard codes were traced,including 51 cases of cardiovascular and cerebrovascular diseases,13 cases of injury and poisoning,12 cases of malignant tumors,9 cases of respiratory system diseases,7 cases of endocrine nutrition and metabolism diseases,musculoskeletal and connective tissue diseases 6 cases,5 cases of mental and behavioral disorders,3 cases of digestive system diseases,3 cases of infectious diseases,2 cases of skin diseases,and 1 case of congenital diseases.There were 89 cases of non-standard causes of death,a decrease of 55.72%compared with the previous one.Conclusions The incomplete traceability of the cause of death chain is the main reason for the non-standard coding of the root cause of death.Strengthening the training of clinicians and improving the completeness of the cause of death chain are the main methods to reduce the non-standard coding of the root cause of death.
作者
王梅
白俊梅
陈黎黎
武宇晨
Wang Mei;Bai Junmei;Chen Lili;Wu Yuchen(Beijing Fengtai District Center for Disease Control and Prevention,Beijing 100070,China;不详)
出处
《中国病案》
2023年第5期16-18,共3页
Chinese Medical Record
关键词
根本死因
不规范编码
死因复核
Root cause of death
Non-standard code
Cause of death review
