摘要
目的通过对2021—2022年无锡市中医医院新版中医临床诊疗术语中临时诊断用术语使用状况进行统计,分析中医编码质量缺陷的原因并提出整改措施,旨在持续提高临时诊断用术语填写质量。方法通过宣传讲解和建立三级质控持续反馈等方法,对2021—2022年无锡市中医医院所有出院中医疾病诊断编码(TCD2021版)中的临时诊断用术语(编码为A17开头的用术语)进行统计,共质控69462份,存在6700份临时诊断用术语。采用SPSS 22.0统计学软件、柱状图、分布图饼图和Excel 2007对问题情况进行描述性统计分析。结果通过整改措施后,临时诊断用术语使用比例由12.06%下降到7.22%,差异有统计学意义(P<0.05)。其中临时诊断用术语共计28个,下降最明显的为眩晕,诊断涉及27个科室,心血管科使用临时诊断用术语下降最多,脾胃病科、普外科和肺病科次之,中医经典科不降反升。结论在多轮培训、三级质控等方法下,出院中医诊断使用临时诊断用术语逐步下降,中医疾病诊断编码质量逐步提升。
Objective Based on the statistics of the use of temporary diagnosis terms in the new version of traditional Chinese medicine clinical diagnosis and treatment terms in Wuxi Hospital of Traditional Chinese Medicine from 2021 to 2022,the causes of defects in traditional Chinese medicine coding quality were analyzed and corrective measures were proposed,aiming to continuously improve the filling quality of temporary diagnosis terms.Methods By means of publicity and explanation and the establishment of continuous feedback of three-level quality control,the provisional diagnosis terms(terms with the code beginning with A17)of all discharged traditional Chinese medicine disease diagnosis codes(TCD2021 version)in Wuxi Hospital of Traditional Chinese Medicine were counted from 2021 to 2022.A total of 69462 quality control documents were obtained.There were 6700 provisional diagnostic terms.SPSS 22.0 statistical software,bar chart,distribution pie chart and Excel 2007 were used for descriptive statistical analysis of the problem situation.Results After the rectification measures were adopted,the proportion of terms used in provisional diagnosis decreased from 12.06%to 7.22%,the difference was statistically significant(P<0.05).Among them,a total of 28 terms were used in temporary diagnosis,the most obvious decrease was vertigo,and the diagnosis involved 27 departments.The use of temporary diagnostic terms in cardiovascular department decreased the most,followed by spleen and stomach diseases,general surgery and pulmonary diseases,and the classical department of traditional Chinese medicine increased instead of decreasing.Conclusion Under multiple rounds of training,three-level quality control and other methods,the use of temporary diagnostic terms in discharged traditional Chinese medicine diagnosis gradually decreased,and the quality of traditional Chinese medicine disease diagnosis coding gradually improved.
作者
张小琳
ZHANG Xiaolin(Department of Medical Records Management,Wuxi Hospital of Traditional Chinese Medicine,Wuxi Jiangsu 214000,China)
出处
《中国卫生标准管理》
2024年第14期65-69,共5页
China Health Standard Management
关键词
中医医院
新版中医诊疗术语
临时诊断用术语
TCD2021版编码
质量改进
措施
hospital of traditional Chinese medicine
new traditional Chinese medicine diagnosis and treatment terms
provisional diagnostic terms
TCD2021 version code
quality
