某院1385份产科住院病案首页主要诊断及编码缺陷分析

Analysis of Main Diagnosis Coding Defect of 1385 Obstetric Records in a Hospital

目的分析某院产科住院病案首页主要诊断及编码存在的问题,提高病案编码质量。方法抽取2017年1月1日-2019年12月31日某院产科出院病案1385份,核查住院病案首页主要诊断及编码,将核对后的错误情况进行统计分析。结果 1385份产科病案中主要诊断及编码错误共217份,错误率15.67%,其中主要诊断过于笼统占48.85%、未使用合并诊断占2.76%、复杂诊断的主要诊断错误占18.89%、主要诊断编码错误占29.49%。错误主要内容为涉及分娩问题的孕产妇医疗占55.76%,产程和分娩的并发症占20.28%,与妊娠有关的其他孕产妇疾患占17.51%。结论培养编码员扎实的编码理论基础及较高的专科知识素养,强化临床医师书写规范,进行有效的双沟通,有利于提高病案编码质量。

Objective To analyze the problems of main diagnosis and coding in the first page of obstetric medical records and improve the record coding quality in a hospital. Methods A total of 1385 obstetrical medical records from January 1, 2017 to December 31, 2019 were selected to verify the main diagnosis and code on the first page of the medical records, and the errors were statistically analyzed. Results There were 217 main diagnosis and coding errors, and the error rate was 15.67%. The main diagnostic general choice accounted for 48.85%, the failure to use the combined encoding accounted for 2.76%, the complex diagnosis selection error accounted for 18.89%, and the main diagnostic coding error accounted for 29.49%. The main contents of the errors were that the medical treatment of pregnant women involved in childbirth accounted for 55.76%, complications of labor and delivery accounted for 20.28%, and the other maternal diseases related to pregnancy accounted for 17.51%. Conclusion It is beneficial to improve the coding quality to train coders with solid coding theoretical foundation and higher specialized knowledge, strengthen the writing standards of clinicians, and carry out effective double communication.