病案首页的主要诊断选择缺陷分析

Analysis of Main Diagnostic Options of Medical Record Front page

目的对住院病案首页的主要诊断选择存在的问题进行统计分析,探讨选择错误的原因,规范对主要诊断的选择,提高病案首页的填写质量。方法回顾性调查分析2016年2月至2017年1月住院病案首页主要诊断选择。结果 9613份出院病案首页的主要诊断符合率90.8%,不符合率9.2%,其中主要原因依次是住院医师选择缺陷、质控医师质控不到位和编码员编码有误。结论针对部分医师对主要诊断选择规则不清楚,疾病诊断名称填写不够规范,组织临床医师进行相关的培训与考核;加大对主要诊断的质控力度,强化医师的责任意识;编码员对主要诊断了解不够,导致编码有误,加强编码员与临床医师沟通,以提高主要诊断的选择的符合率。

Objective To make a statistical analysis of the main problems in the selection of the first page of inpatient medical records, to explore the causes of inconsistent selection, to standardize the selection of the main diagnosis, and to improve the quality of filling the front page of medical records. Methods A retrospective investigation was conducted to analyze the main diagnostic options for the first page of inpatient medical records from February 2016 to January 2017. Results The main diagnostic coincidence rate of the first page of the 9613 discharged medical records was 90.8%, and the rate of non compliance was 9.2%. The main reasons were the defects of the resident doctor selection, the quality control of the quality control doctors and the coding errors of the coders. Conclusion For some physicians on the main diagnostic selection rules are not clear, fill in the name of the diseases are not standardized, the organization of training and assessment of relevant clinicians; increase efforts to control the main diagnostic, strengthen the sense of responsibility of the physician; encoding member of main diagnosis grasp is not enough, resulting in encoding error, strengthen encoding staff and clinicians to communicate with improve the coincidence rate of diagnosis of major selection.