某三级综合医院215份歧义病案分析

Analysis of 215 Ambiguous Medical Records in a Tertiary General Hospital

目的分析某三级综合医院215份歧义病案产生原因,提出降低歧义病案发生率的改进措施。方法从病案信息系统导出2019年1月1日-2019年12月31日出院患者的住院病案首页数据,并导入智能编码质控平台进行处理后,得到未入组的215份歧义病案,依据主要诊断选择原则及国际疾病和手术操作编码规则,查看病案分析不入组的原因,利用Excel2010进行汇总统计。结果 215份歧义病案涉及全院每个科室,消化内科例数最高,占比20.46%;仅主要诊断错误、主要手术操作错误、同次住院治疗多种疾病、主要诊断和主要手术操作均错误等四种情况,占比分别为47.91%、34.42%、13.02%、4.65%;错误责任人分为编码员、临床医师、两者均有错误,其中主要诊断错误113份,占比分别是51.33%、48.67%、0%,主要手术操作错误84份,占比分别是85.72%、9.52%、4.76%;编码知识欠缺、临床知识不足和粗心大意是编码员编码出错的三大原因。结论加强临床医师规范化培训、提升编码员综合临床思维、优化科室管理、注重对同次住院治疗多种疾病的管理,是降低歧义病案发生率的有效措施。

Objective Analyze the causes of 215 ambiguous medical records in a tertiary general hospital, and propose improvement measures to reduce the incidence of ambiguous medical records. Methods The first page data of discharged patients’ medical records from January 1, 2019 to December 31,2019 was exported from the medical record information system and imported into the intelligent coding quality control platform for processing. 215 ambiguous medical records were obtained. According to the main diagnosis selection principles and international classification and coding rules of disease and operation,the reasons for not entering the group were analyzed by viewing the medical records and summarized by Excel2010. Results 215 ambiguous medical records involved every department of the hospital,with the highest number of gastroenterology cases,accounting for 20.46%;only major diagnostic errors, only major surgical operation errors, hospitalization for multiple diseases at the same time, major diagnosis and major surgical operations accounted for 47.91 %, 34.42%, 13.02%, 4.65%;the person responsible for the errors was divided into coders, clinicians and both were wrong, including 113 major diagnostic errors, accounting for 51.33%, 48.67% and 0% respectively, 84 major surgical operation errors, accounting for 85.72%, 9.52% and 4.76% respectively;lack of coding knowledge,lack of clinical knowledge and carelessness were the three main reasons for coding errors. Conclusions Strengthening the standardized training of clinicians, improving the comprehensive quality of coders, optimizing the management of department,and increasing the management of multiple diseases in the same hospitalization are effective measures to reduce the incidence of ambiguous medical records.