住院病案首页主要诊断及主要手术操作编码持续性质控的效果分析

Analysis of the Effect of Continuous Quality Control on the Main Diagnosis and Main Surgical Operation Coding on the First Page of Inpatient Medical Records

目的探讨对住院病案首页主要诊断和主要手术操作编码开展持续性质控的价值。方法选取2021年1月—2022年12月涟水县中医院25名医师与5名编码员,2021年1—12月为质控前进行常规病案管理,纳入600份病历首页;2022年1—12月为质控后采用持续性质控方案,纳入600份病历首页。比较质控前后编码错误率。结果在主要诊断编码错误情况上,质控后总错误率(9.00%)、医师错误率(5.17%)以及编码员错误率(3.83%)均低于质控前;在主要手术操作编码上,质控后总错误率(11.25%)、医师错误率(5.31%)以及编码员错误率(5.94%)均低于质控前,差异有统计学意义(P<0.05)。结论通过持续性质控能有效降低住院病案首页主要诊断以及手术操作编码错误率,基于质控后编码错误原因,应当重点针对医师填写错误以及编码员错编问题进行干预。

Objective To explore the value of continuous quality control on the main diagnosis and main operation codes on the first page of inpatient medical records.Methods From January 2021 to December 2022,25 doctors and 5 coders from Lianshui County Hospital of Traditional Chinese Medicine were selected.From January 2021 to December 2021,routine medical record management was carried out before quality control,and 600 medical records were included in the first page of medical records.From January to December 2022,a continuous quality control plan was adopted after quality control,and 600 medical records were included on the homepage.Compare the coding error rates before and after quality control.Results In terms of main diagnostic coding errors,the total error rate(9.00%),physician error rate(5.17%),and coder error rate(3.83%)after quality control were lower than before quality control.In terms of coding for major surgical procedures,the total error rate(11.25%),physician error rate(5.31%),and coder error rate(5.94%)after quality control were lower than before quality control,the difference was statistically significant(P<0.05).Conclusion Continuous quality control can effectively reduce the coding error rate of major diagnoses and surgical procedures on the first page of inpatient medical records.Based on the reasons for coding errors after quality control,interventions should focus on the problems of physicians'filling errors and coders'errors.