疾病编码的质量分析与对策

The quality analysis and its countermeasures of diseases coding

目的通过对病案的疾病编码进行回顾性质量分析,找出问题与差距,以提高疾病编码的准确性。方法根据国际疾病分类的编码原则,对1200份出院病案进行编码检查。结果 1200份病案中有358份病案编码存在问题,错误率为29.8%。结论加强编码员的专业知识以及相关临床知识的培训,并制订相关制度和奖惩机制,以提高疾病编码的水平。

Objective To investigate the problems and differences through making a retrospective quality analysis to the coding of diseases, thus in- crease the veracity. Methods Check-up the coding of 1200 medical records according to the coding rules in national diseases classification. Results There are 358 of 1200 medical records existing problems and error rate is 29.8%. Conclusion By strengthen the training of the clinical and professional knowledge of diseases coders, company with related rules drawing as well as reward and punishment mechanism, can we expect to improve the level of diseases coding.