某三甲综合医院2018年病案编码质量分析与改进对策

Quality Analysis and Improvement Measures of Medical Record Coding in 2018 in a Top Three General Hospital

目的探讨广东省惠州市某三甲综合医院2018年病案编码质量监控,核查和分析某院住院病案首页的疾病诊断和手术操作编码情况,提出改进措施,旨在提高全院病案编码质量与管理水平。方法对2018年1月1日-2018年12月31日全院出院病案87 147份进行随机抽样,核查样本的疾病诊断和手术操作编码,对结果进行统计分析。结果在编目工作强度近似条件下,编码员的专业素养和工作经验不高会造成病案编码错误率升高,具有统计学意义,P=0.001。在抽样4176份病案中,有3956份病案编码正确,正确率为94.73%,而编码存在错误的有220份,错误率为5.27%。其中,由于编码人员自身问题、临床医师不正确填写和病案相关信息系统问题导致的编码错误率占比分别为4.74%、0.43%和1.82%;主要诊断疾病编码、其他诊断疾病编码、主要手术操作编码和其他手术操作编码的错误率依次占5.83%、20.00%、18.33%和55.83%;手术科室的不合格编码病案居多。结论重视编码员专业知识和职业素养的培养,加强医师和编码员的培训与沟通,完善和优化病案信息相关系统和病案编码知识库,促进全院病案编码准确率与效率进一步提升。

Objective To explore the quality control of medical record coding in a third class A general hospital in Huizhou City,Guangdong Province in 2018,check and analyze the disease diagnosis and operation coding on the front page of medical record in a hospital,and put forward improvement measures to improve the quality and management level of medical record coding in the hospital.Methods 87147 medical records discharged in the hospital from January 1,2018 to December 31,2018 were randomly sampled,the disease diagnosis and operation coding of the samples were checked,and the results were statistically analyzed.Results Under the condition of similar cataloguing work intensity,the low professional quality and work experience of the coder will increase the error rate of medical record coding,which is statistically significant(P=0.001).Of the 4176 medical records sampled,3956 were coded correctly,with an accuracy rate of 94.73%,while 220 were coded incorrectly,with an error rate of 5.27%.Among them,the coding errors caused by the coding personnel’s own problems,the clinician’s incorrect filling in and the medical record related information system problems accounted for 4.74%,0.43% and1.82% respectively;the error rates of the main diagnosis disease coding,other diagnosis disease coding,main operation coding and other operation coding accounted for 5.83%,20.00%,18.33% and 55.83% respectively;There are many unqualified coding medical records in the surgical department.Conclusion Pay attention to the training of professional knowledge and professional quality of coders,strengthen the training and communication between doctors and coders,improve and optimize the relevant system of medical record information and the knowledge base of medical record coding,and further improve the accuracy and efficiency of medical record coding in the whole hospital.