某区域医疗中心85份QY病案分析

An Analysis of 85 QY Cases in a Regional Medical Center

目的通过对QY病案的梳理和错误原因分析,探讨有效提高编码质量的方法与途径。方法利用北京地区住院医疗服务绩效评价平台提供的某院2018年1月1日-2018年12月31日85份QY病案,通过查阅病案首页、手术记录和出院记录等方法得到编码不入组原因并绘制图表进行分析。结果QY病案中医师对主要诊断选择错误为25例,占比为29%,肿瘤科错误最多为17例,错误占比68%;编码员对主要诊断或手术操作的编码错误53例,错误占比63%,其中因为缺乏临床知识错误20例,错误占比38%,由于编码知识欠缺错误12例,错误占比22%,因为疏忽大意错误21例,错误占比40%;疏忽大意错误最多的时间为星期一,13例,错误占比63%;同次住院转科治疗2种不同种疾病7例,错误占比为8%,其中转科科别均为五官科。结论出现QY病案的主要原因是临床医师对主要诊断和手术操作的选择出现偏差、编码员对临床知识和编码规则的掌握存在不足、过分依赖拼音缩写进行编码导致的疏忽大意错误,同次住院转科治疗2种疾病等也是产生QY病案的原因之一。

Objective To explore the methods and ways to improve the quality of coding by sorting out QY medical records and analyzing the causes of errors.Methods 85 QY medical records from January 1,2018 to December 31,2018 in a hospital provided by the performance evaluation platform of inpatient medical service in Beijing were used to obtain the reasons for the uninclusion of codes and draw charts for analysis by querying the front page of medical records,operation records and discharge records.Results There were 25 cases(29%)of errors in the diagnosis of QY,and 17 cases(68%)of errors in oncology.Among the 53 cases of coding errors in major diagnostic or surgical operations,errors accounted for 63%,among which 20 cases were errors due to lack of clinical knowledge,38%were errors,12 cases were errors due to lack of coding knowledge,22%were errors,and 21 cases were errors due to negligence,40%were errors.The most careless mistakes were made on Monday in 13 cases,accounting for 63%of the errors.In the same time,7 patients were transferred to different departments for treatment of two different diseases.Conclusions The main cause of QY medical record including clinicians errors occurring in the selection of main diagnosis and surgical operation,coders were insufficient to clinical knowledge and the encoding rules,excessive reliance on pinyin initials coding lead to careless errors,change one’s major with time was in the hospital treatment of both diseases was one of the causes of QY medical record.