疾病与手术分类编目质量核查系统开发与应用

Development and Application of Classification Quality Checking System

病案首页诊断、手术编目的准确与否,直接影响医疗保险结算、医疗信息统计等工作,是医院等级评审的重要指标。快速、准确、及时的发现编目问题并予以更正,是提高病案首页的数据质量的关键。通过计算机软件自动核对诊断、手术描述与疾病编码,筛选出不符合的条目,并在计算机辅助下快速人工分析汇总,按科室、医生、编目员分别生成描述问题、编目问题等报表。既解决了大量繁琐的核对工作,又分门别类的汇总了各类人员存在的问题,以便有针对性的解决问题。保证了病案首页诊断编码符合率,提高了工作效率和质量。同时也为工作绩效提供了考评信息。

The accuracy of diagnosis of the front sheet and operation＇ s code influences medial insurance and statistics immediate- ly and is the significant standard of evaluating the level of hospital. To find and correct the problems rapidly, accurately and immediately is the key to improve the data quality of the front sheet of medical records. Computer can automatically cheek diagnosis operation description and disease codes. It can also assist people to analyze information and make report. It can easily deals with the repetitive work and various difficulties, enhance the efficiency accuracy and quality and offer the information in terms of evaluating working performance, ensure diagnosis encoding coincidence rate of the front page and improves the work efficiency and quality, at the same time provide assessment information for performance.