病历书写质量对疾病编码正确性的影响

Influence of Medical Record Writing Quality on the Correctness of Disease Coding

目的分析病历书写质量对于疾病编码正确性的影响。方法随机选取我院于2018年7月至2019年7月,此1年时间段内收集的疾病编码错误案例共224份,分析所有发生疾病编码错误案例的错误原因,并针对此提出具有可行性的、针对性的改善方法。结果所有224份疾病编码错误案例中,154份(68.75%)是由电子病历填写质量低下导致,同时导致编码错误的因素还包括:编码人员自身专业能力不足29份(12.95%)、病历书写与患者实际情况不符17份(7.59%)、病程记录不全9例(4.02%)、未严格按照编码流程执行7例(3.13%)、未详细记录治疗流程8例(3.57%)。结论电子病历填写质量对疾病编码正确性有较大且直接的影响,需提出完善、科学、有效的疾病编码操作流程,并加强对疾病编码人员的职业培训,提升其职业能力,从而有效提高疾病编码的正确性。

Objective To analyze the influence of medical record writing quality for correctness of disease coding.Methods Two hundred and twenty-four cases of disease coding errors in our hospital from July 2018 to July 2019 were randomly selected,and the error causes of all cases of disease coding errors were analyzed,the feasible and targeted improvement methods were put forward.Results Two hundred and twenty-four cases with wrong coding,154 copies were due to the poor quality of filling in electronic medical records,accounting for 68.75%.The factors that lead to coding errors including:the professional ability of coders was less than 29(12.95%),the writing of medical records was not consistent with the actual situation of patients 17(7.59%),the course of disease was not recorded in 9(4.02%),the coding process was not strictly followed in 7(3.13%),the treatment process was not recorded in detail in 8(3.57%).Conclusion The quality of electronic medical record filling has great and direct influence on the correctness of disease coding,which the correctness of disease coding may be affected by the professional ability of the coder,so as to effectively improve the correctness of disease coding.