广西省13家医院出院病案首页编码质量及影响因素的调查

Research on the Current Situation of Front Pages Coding Quality in Discharged Medical Records of 13 Hospitals in Guangxi Province and Relevant Influencing Factors

目的了解广西省病案首页编码质量现状,为地区推行医疗保险付费制度改革及决策提供依据。方法采用横断面研究方法,利用方便抽样选取广西省内9所三级和4所二级医疗机构,通过实地调研、问卷调查及随机抽取病案相结合的形式对病案首页编码质量进行评价,并探讨其影响因素。13所医院共抽取2014年出院病案1314份。结果二级医院编码员配置严重不足,三级医院拥有资质的编码员比例高达93.2%;主要诊断、其他诊断、主要手术/操作及其他手术/操作整体错误率(中位数)分别为27.3%(23.8%),25.7%(24.8%),21.1%(19.4%),84.2%(100.0%);医师编码模式导致的各类别错误率均高于传统编码员编码模式,P<0.01;二级医院比三级医院编码错误率高,P<0.05;追溯原因,在导致以上错误的各类原因中,医师相关责任较单纯编码员责任占比高,分别占主要诊断及主要手术/操作编码错误的55.4%和52.3%。结论病案首页编码质量与国家标准相比仍有差距。编码质量与医院级别、编码方式密切相关。采用医师编码的方式大大增加编码错误风险,应改进系统,使病案首页信息管理具有独立性。

Objectives To explore the current situation of front pages coding quality in discharged medical records, and provide the basic data for the reform and implementation of the medical insurance payment system in Guangxi province. Methods A cross-sectional study was conducted in form of combination of field visits, questionnaire survey and random sampling of cases. Nine tertiary and four secondary hospitals were conveniently sampled and at least 100 cases were selected in each hospital to evaluate the accuracy of discharge coding, on which influencing factors was explored. Results Shortage allocation of coders existed in secondary hospitals and the proportion of qualified coders was up to 93.2% in tertiary hospitals. 1314 cases were randomly selected from 13 hospitals. The overall error rate（median） of the primary diagnosis,other diagnosis,major operations/procedures and other operations/ procedures were 23.8%（20.4%）,24.8%（11.5%）,19.4%（19.5%） and 100%（24.3%） respectively. The error rate of physician coding mode in all error categories were higher than that of traditional coding mode, P 〈 0.01 and the error rate of secondary hospitals were also higher than that of tertiary hospitals, P〈0.05. Physician-related error rate was 55.4% and 52.3% for primary diagnosis and major operation/procedure respectively, which was higher than rate of errors caused by traditional coders only. Conclusions There was still a gap between coding accuracy and national standard in the certain area. Coding accuracy is closely related to hospital level and coding mode. The mode of physician as medical coder greatly increases the risk of coding errors. The current system should be modified to ensure that medical record home page management system being independent to HIS for traditional coder.