某儿童医院384例QY病案住院病案首页缺陷相关分析

Correlation Analysis on Defect of Home Page in 384 Cases of Medical Records in Children Hospital

目的分析某儿童医院QY病案住院病案首页主要诊断与主要手术操作填报中存在的问题,为持续改进住院病案首页填写质量提供依据。方法调取某儿童医院2019年1月1日-2019年12月31日住院病案首页DRGS分组产生的QY病案384例,组织高年资临床医师和编码员,通过查阅住院病案首页主要诊断和手术操作与病案中手术记录,获得产生QY病案的原因并进行回顾性统计分析。结果QY病案占分组病例数的0.6%(384/64346),其中内科占32.8%(126例)、外科占67.2%(258例),分布25个科室、占科室总数83.3%。临床医师主要诊断错误占55.8%(72/129)、手术操作错误占67.8%(194/286),编码员主要诊断编码错误占44.2%(57/129)、主要手术操作编码错误占32.2%(92/286),转科治疗2种不同疾病导致QY病案占15.6%。结论临床医师未掌握住院病案首页主要诊断和主要手术操作选择原则,编码员临床专业知识的局限性、编码规则掌握不准确是产生QY病案的主要原因。应加强临床医师住院病案首页规范填写与编码员编码技能培训。

Objective This paper analyzes the problems existing in primary diagnosis and main operative procedure of QY medical records in hospital medical records in a children hospital providing basis for improving quality of primary page filling in inpatient records.Methods 384 cases of QY medcal records were obtained from front page of medical record from January 1 st 2019 to December 31 st 2019.Senior doctors and coders were organized.Through consulting primary diagnosis operation records of QY medical records and reviewing statistical analysis through consulting primary diagnosis operation and operative records of medical records.Results There were 0.6%cases(384/64346)cases in group Internal medicine accounting for 32.8%(126 cases)surgical accounting for 67.2%(258 cases)distributing 25 departments accounting for 83.3%departments.Conclusion Clinicians do not master the main diagnosis and main surgical choice principles of primary medical records of hospitalized medical records and limitations of professional knowledge of coders and inaccurate coding rules are main reasons for producing QY medical records.We should strengthen the teaching of standard filling of primary page of clinical doctors and coding skill training.