病案编码质量分析与改进对策

Analysis on the Quality of Medical Record Coding and Improvement Countermeasures

目的通过对2017年某院病案首页数据中的疾病和手术操作编码进行回顾性检查,分析病案编码中常见错误的原因,旨在于找出能提高疾病与手术操作编码准确率的对策,探索改进措施,提升医院病案编码水平。方法采用分层抽样法对2017年全年出院病案进行抽查,并由科室内从事病案编码工作20年以上的编码人员逐一检查病案中诊断及手术操作的ICD编码情况并做出相应分析。结果对4550份出院病案进行核查,共存在编码错误214份,错误率4.7%,其中142份病案是编码人员错误编码,错误率为3.12%。结论加大力度抽查病案编码情况,及时反馈与学习,系统培训编码员,建立奖惩制度,增强编码人员责任心,与临床医师建立良好的沟通,可提高病案首页编码准确率,从而促进编码质量的提升。

Objective Through retrospective examination of disease and operation coding in the front page of medical records of a hospital in 2017,the causes of common errors in medical records coding were analyzed in order to find out countermeasures to improve the accuracy of disease and operation coding,explore improvement measures and improve the level of hospital medical records coding.Method A stratified sampling method was used to sample the discharged medical records in 2017.The ICD codes of diagnosis and operation in the medical records were checked and analyzed by the coders who worked in the Department for more than 20 years.Results A total of 214 coding errors were found in 4550 discharged medical records,with an error rate of 4.7%.Among them,142 were coded errors by coders,and the error rate was 3.12%.Conclusion Enhancing the strength of spot check of medical record coding,timely feedback and learning,systematic training of coders,establishing reward and punishment system,enhancing coders’ sense of responsibility,and establishing good communication with clinicians can improve the accuracy of medical record coding,thus promoting the quality of coding.