某院715份产科病案疾病编码质量分析

Quality Analysis on Coding Quality of 715 Obstetric Cases in a Hospital

目的监测某院产科病案疾病编码质量,寻求提高编码质量与效率的方法。方法利用系统抽样法按照15%的比例对2016年7月-2017年6月全院产科出院病案4769份进行抽样,核查样本的疾病诊断编码,进行统计分析。结果抽样715份病案中编码存在错误的有40份,错误率为5.6%。其中主要诊断错编占37.5%、其他诊断错编占35.0%、漏编其他诊断占12.5%等。分析结果显示诊断编码主要错误项目为产科情况涉及发病时期占37.5%、分娩结局占25.0%、产科出血性疾病占15.0%。结论注重编码员专科知识学习及提高编码水平、强调临床医师书写准确、加强编码员与临床医师的沟通有利于提高病案编码的准确率与效率。

Objectives To conduct monitoring on the coding quality of medical records of a hospital,analyze the reasons causing wrong coding,exploring the methods of improving coding accuracy. Methods A sampling of 4,769 obstetric discharge cases was conducted from July 2016 to June 2017 at the rate of 15%,inspect and analysis the diseases coding situation. Results There were 40 errors in the 715 cases of medical records,and the error rate was 5.6%. The error rate of ICD-10 coding of the main diagnosis accounted was 37.5%,for other diagnosis was 35.0%,and forget other diagnostic codes was 12.5%. The results showed that the main errors in the coding of diseases were 37.5% of the cases of incidence period in obstetrics,25.0% of the delivery outcome and 15.0% of obstetric hemorrhagic diseases. Conclusions Pay attention to the coder＇s specialized knowledge learning and improve the coding level,emphasize the doctor＇s accurate writing of the medical record and strengthen the communication between the coder and the doctor,thereby improving the coding accuracy and efficiency.