某医院2021年住院病案首页ICD编码质量分析

ICD coding quality analysis of the first page of inpatient medical records in a hospital in 2021

目的对某医院2021年住院病案首页ICD编码错误情况进行分析,找出编码错误原因,提出持续改进举措,提高ICD编码质量。方法根据医疗保障基金结算清单填写规范中关于疾病诊断和手术/操作的填报要求,各科质控员对出科病案进行初步质控;病案归档后病案编码员进行二次质控;最后由高年资编码质控员进行审核汇总,利用Excel表格详细记录2021年1月1日至12月31日各科室ICD编码错误情况,统计编码错误类别分布。结果2021年各临床科室出院病案共计10860份,编码错误病案1710份,编码错误率15.75%。主要诊断编码错误(错编、与核心治疗不符、与主要手术/操作不符)构成比8.53%;其他诊断编码错误(错编、多填其他诊断、漏填其他诊断)构成比52.28%;主要手术/操作编码错误(名称填写错误、漏填、错编、未和主要诊断对应)构成比2.16%;其他手术/操作编码错误(错编、多填、漏填)构成比37.02%。结论医院管理层面、医生层面、编码员层面都对ICD编码质量有着重要影响,通过建立DRG运行机制、定期开展双向培训、完善电子病历编码校验功能等持续改进措施,能够减少ICD编码错误率。

Objective To analyze the ICD coding errors on the first page of inpatient medical records in a hospital in 2021,find out the causes of coding errors,and put forward continuous improvement measures to improve the quality of ICD coding.Methods According to the filling requirements of disease diagnosis and surgery or operation in the filling specification of medical security fund settlement list,the quality control personnel of each department carried out preliminary quality control for the medical records.After the medical records were filed,the medical record coder carried out secondary quality control.Finally,the senior coding quality control personnel reviewed and summarized the ICD coding errors of each department from January 1,2021 to December 31,2021,and recorded the distribution of coding error categories.Results In 2021,there were 10860 medical records of discharged patients in each clinical department,with 1710 wrong coding medical records,and the coding error rate was 15.75%;the proportion of major diagnostic coding errors(wrong coding,inconsistent with core treatment,inconsistent with main surgery or operation)was 8.53%;the proportion of other diagnostic coding errors(wrong coding,overstatement of other diagnosis,omission of other diagnosis)was 52.28%;the proportion of major surgery or operation coding errors(name filling error,omission,wrong coding,not corresponding to the main diagnosis)was 2.16%;other surgery or operation coding errors(wrong coding,over filling and missing)accounted for 37.02%.Conclusion Hospital management,doctors and coders all have important impacts on the quality of ICD coding.Through continuous improvement measures,such as establishing DRG operation mechanism,carrying out bidirectional training regularly,and perfecting electronic medical record coding verification function,the error rate of ICD coding can be reduced.