493份死亡病案首页诊疗信息填报质量分析

Analysis of Reporting Qualityof 493 Death Records Treatment Informationof the Front Page

目的通过对某三甲医院死亡病案首页诊疗信息的填报质量分析,明确临床医师与编码员在病案首页填报中存在的问题及改进方法。方法选取2015年10月1日-2016年9月30日死亡病案493份,病案质控医师以相同标准对临床医师填报及编码员ICD编码后的病案首页诊疗信息进行对照检查,检查结果经病案科、医院质量控制与评估办公室、临床医师共同确认后进行汇总分析。结果病案首页诊疗信息填报完全正确率:临床医师为10.14%,编码员为30.02%;临床医师主要诊断填写错误与不准确合计占到38.24%,其他诊断漏诊占44.49%,其他手术/操作漏填占到43.01%。结论临床医师及编码员在病案首页信息的正确上报中起着至关重要的作用。加强临床医学知识和主要诊断选择原则的相关培训,以及临床医师和编码员密切沟通是提高病案首页填报质量的最佳途径。

Objective Through the analysis of reporting quality of 493 death records treatment information of the front page in a hospital, to clear and definite the problems and improvement methods of the clinical physicians and the coding staff in the front page of medical records. Methods 493 death medical records from October 1, 2015 to September 30, 2016 were selected. The medical record quality control doctor with the same standard for clinical physicians to fill out the information of the first page of the medical record after ICD coding. The medical records, hospital quality control and evaluation office, and the clinician together to confirm the summary analysis. Results The correct rate of Diagnosis and treatment information： Clinicians 10. 14%, the coders 30. 02%; the main diagnostic errors and inaccurate accounting for 38.24% of the total, the other diagnosis of missed diagnosis accounted for 44. 49%, other surgery / operation leakage accounted for 43.01%. Conclusion The clinician and the encoding member plays a crucial role in the correct reporting of information of the first page. The relevant training to strengthen the clinical medical knowledge and diagnostic selection principle, close communication between clinicians and staff is the best way to improve the encoding of medical record quality reporting.