400份住院病案首页诊疗信息错误类型分析

Analysis of the Errors Types of Medical information in the Front Sheet of 400 Cases of Medical Records

目的基于实证数据分析某市8所医疗机构住院病案首页的诊疗信息、错误类型以评价其住院病案首页质量。方法根据医院类别随机抽取该市8所医院合计400份病案,由临床医师和编码员组成督察小组,对病案诊疗信息进行现场核查;并对其诊疗信息错误类型进行统计分析。结果本次督查住院病案首页诊疗信息的总体错误率为43.25%。其中主要诊断的错误率为25.50%,以错误选择(37.25%)为主;其他诊断的错误率为21.75%,以漏填(13.75%)为主;主要手术操作的错误率为11.25%,以选错和漏填为主,错误率均为8.25%;其他手术操作的错误率达到12.13%,以漏填(16.25%)为主。结论本次被督查医院的住院病案首页质量总体上与现有标准和其他研究结果存在较大差距,卫生行政部门需要重点关注主要诊断的选错和错编、其他诊断和手术操作的漏填问题,采取有针对性的措施来缩小差距提高诊疗数据质量。

Objective Based on empirical data,Errors Types of medical information was analyzed to evaluate its quality on the Front Sheet of Medical Records.Methods According to the hospital category,a total of 400 medical record were randomly selected from 8 hospitals in the city.An inspector group consisting of clinicians and coders conducted on-site inspection on the coding of the medical record.And analysis on theerrors types of medical information.Results The overall error rate of themedical informationin this inspectionwas 43.25%.The main diagnostic error rate was 25.50%,which was dominated by the wrong choice(37.25%).The other diagnostic error rate was 21.75%,mainly due to missing filling(13.75%).The main surgical operation error rate was 11.25%,mainly due to wrong choice and missing filling,and the error rate of which was both 8.25%.The error rate of other surgical operations reached 12.13%,mainly due to missing filling(16.25%).Conclusion The coding quality level of hospitals in the city is generally far from the existing standards and other research results.Hospital administrators need to focus on the problems of the wrong choice and misclassification about themajordiagnoses,and the missing fill of the other Diagnostic and surgical operation,take targeted measures to narrow the gap and improve the quality of coding.