摘要
目的对病案首页填写过程中出现的问题进行探讨和研究。方法运用数量分析和统计学方法,收集、分析、整理昆明市某三甲医院病案首页信息。结果入组前常出现的问题为编码错误,胃肠外科在消化系统恶性肿瘤编码方面管理较差;入组后常出现的问题为诊疗信息选择错误,同时发现医院部分病案存在高编现象。结论应提高医师和编码员责任意识和对病案首页的重视程度,积极开展病案首页内容填写的培训和考核,优化病案质量控制流程。
Objective:To discuss and study the problems in the process of filling in the home page of medical record.Method:The home page information of medical records was collected and analyzed by taking a hospital of 3 A grade in Kunming as an example,combining quantitative analysis with statistical analysis.Result:The common problem before enrollment was coding error.Meanwhile,it was found that the gastrointestinal surgery was poorly managed in the coding of malignant tumors in the digestive system.The common problem after enrollment is the wrong selection of diagnosis and treatment information.And it was found that some medical records in the hospital were overwritten.Conclusion:It is necessary to improve the responsibility awareness of physicians and coders and attach importance to the home page of medical records,actively carry out the training and assessment of filling in the home page of medical records,and optimize the quality control process of medical records.
作者
曹雪苹
高华斌
何梅
CAO Xue-ping;GAO Hua-bin;HE Mei(School of Humanities and Management,Kunming Medical University,Kunming 650500,China;First Affiliated Hospital of Kunming Medical University,Kunming 650000,China)
出处
《现代医院管理》
2021年第1期34-38,共5页
Modern Hospital Management
基金
云南省医疗保险基金管理中心课题(2017HP013)
昆明医科大学“十三五”学科建设成果
2018年度云南省教育厅科学研究基金项目“DRGs与医院内部控费动力的研究”研究成果。
