病案首页质量控制对主要诊断填报质量的影响

The Influence of Quality Control in Front Pages of Medical Records to the Filling Quality of Principal Diagnosis

目的探讨病案首页质量控制在提高病案首页主要诊断填报质量中的作用。方法根据国际疾病分类规则和主要诊断选择原则判断主要诊断填写和疾病编码的正确性,分别检索2014年-2015年脑血管病的病案,统计病案首页质量控制前后错误发生例数并计算错误率。结果脑血管病的主要诊断错误率采用病案首页质量控制前是5.33%,采用病案首页质量控制后是1.98%。结论采用病案首页质量控制方法不仅能够提高主要诊断填报的正确率,而且可以逐步规范临床医师对疾病诊断名称的书写,使得疾病编码质量稳步上升。

Objective To investigate the function of quality control in front pages of medical records to the improvement of filling quality of principal diagnosis. Methods To make judge on the accuracy of principal diagnosis filling and diseases coding according to the International Diseases Classification rules and principal diagnosis selection rules, search the medical records of cerebrovascular diseases in the whole year of 2014 and 2015. To calculate the error cases number before and after the quality control as well as error rate, and calculate P score with the application of chi-square test. Results The error rates of principal diagnosis of cerebrovascular diseases were 5.33% and 1.98% respectively before and after quality control. Conclusions The application of quality control method in front pages of medical records could not only improve the accuracy of principal diagnosis filling, and also could standardize the writing of diseases diagnosis names of clinical physicians gradually, thus to promote the quality improvement of diseases coding.