福建省某三级医院编码培训前后质量变化分析

Analysis of the Reasons for the Changes before and after the Quality Training of the Front Page of Medical Records in a Tertiary Hospital in Fujian Province

目的分析福建某三级公立综合医院病案科加强专业系统培训后对病案首页编码质量的影响。方法对全部编码员统一进行国际疾病分类和手术操作分类的培训,将2017年10月-2018年10月培训后完成病案首页疾病和手术编码的出院病案作为研究组,将2016年8月-2017年8月培训前完成的病案首页疾病和手术编码的出院病例作为对照组,对比2组病案的疾病主要诊断编码、主要诊断编码残余类目数、病种数、手术操作病案数、手术操作总条目数。结果研究组平均诊断编码为6条、收治病种数1498种、非残余类目数1120条,均高于对照组;研究组残余类目数为378条,少于对照组。统计病种数增加(P<0.001);研究组平均出院病案手术操作编码条目数为4条、手术操作编码总数目为14823条、操作编码病例数为8694例,均高于对照组,差异具有统计学意义(P<0.05)。结论通过加强科室专业病案质量培训的学习,编码员的病案首页疾病和手术编码能力得到了提高,同时也使医院统计病种数更加精准。加强编码质量专业系统培训是提高病案首页编码质量以及提升医院统计能力的有效途径。

Objectives To analyze the effect of strengthening professional system training on the quality of the front page of medical records in the medical records department of a tertiary general hospital in Fujian province and its causes. Methods The discharged patients who completed the disease and operation codes on the front page of medical records after training and learning from October 2017 to October 2018 were taken as the research group, and the discharged patients who completed the medical records codes before training and learning from August 2016 to August 2017 were taken as the control group. The number of main diagnostic codes and residual categories of main diagnostic codes were compared between the two groups. The number of diseases, operation cases and total operation items were counted. Results The results showed that the average number of diagnostic codes(n = 6.00), the number of treated diseases(n = 1498), the number of non-residual categories(n = 1120) in the study group were higher than those in the control group(n = 2.00), the number of treated diseases(n = 1169), and the number of non-residual categories(n = 597), while the number of residual categories(n = 378) in the study group was lower than that in the control group(n = 572). The number of operation codes(n=4.00), the total number of operation codes(n=14823),and the number of operation codes(n=8694) in the study group were significantly higher than those in the control group(n=2.00), the total number of operation codes(n=7912), and the number of operation codes(n=911). It has obvious statistical significance(P<0.05). Conclusions Through strengthening the study of professional medical record quality training in departments, the coding ability of the coder for diseases and operations on the front page of medical records has been improved. At the same time, the number of diseases in hospital statistics has been more accurate.Therefore, strengthening the training of coding quality professional system is an effective way to improve the coding quality of the front page of medical records and enhance the statistical ability of hospitals.