某大型教学医院临床医生编码疾病主要诊断的持续性改进研究

Research on the Continuous Improvement of the Quality of Disease Major Diagnosis Coding by Clinicians in A Large Teaching Hospital

目的鼓励临床医生编码疾病主要诊断,提高医院疾病主要诊断编码正确率。方法分析2012年1月-2013年6月临床医生疾病主要诊断编码情况,了解实行临床治疗组长负责疾病编码,病案科编码人员针对各临床科室疾病特点对临床医生进行国际疾病分类知识的介绍,并与临床医生就疾病编码问题进行实时沟通与交流的方法能否提高疾病主要诊断编码正确率。结果全院临床医生主要诊断编码率从94.081%提高至98.301%,编码正确率从75.824%下降至67.483%,最后达到81.893%。结论鼓励临床医生编码疾病主要诊断,实行临床治疗组长负责制,可提高主要诊断编码的准确性,加强临床科室与病案科之间的交流,有助于疾病编码质量得到持续不断的改进。

Objective To encourage clinicians to code the major diagnosis of diseases, in order to improve the correct rate of disease major diagnosis coding. Methods We analyzed the data of major diagnostic codes by clinicians from January 2012 to June 2013. The group leader of the clinical treatment was designated to be responsible for the disease coding. Disease coders introduced knowledge of international classification of diseases to the clinical department according to the different characteristics of disease in each department and communicated with clinicians on the problems of disease coding. Then, we tried to find out whether this method could improve the correct rate of major diagnosis coding of diseases. Results The rate of disease major coding by clinicians of the whole hospital and pilot departments increased from 94.081% to 98.301%. The correct rate of disease major coding decreased from 75.824% to 67.483% and then reached 81.893%. The correct rate of disease major coding of the Department of Hematology was 83.824% in August 2012 and then decreased with the lowest rate of 68.025%; and the correct rate of disease major coding of the Department of Orthopedics increased rapidly and reached 90% in September 2012. Conclusions Through the leader of the clinical treatment being responsible for the disease coding and encouraging clinicians to code the main diagnosis of diseases, the accurate of disease major diagnosis coding has improved. Strengthening the communication between clinical and Medical Record Departments can help our hospital improve the quality of disease major diagnosis coding continuously.