医院病案首页数据病案编码情况及改进措施分析

Analysis of Medical Record Coding Situation and Improvement Measures in the Front Page of Hospital Medical Record

目的分析在医院病案首页数据病案编码情况以及改进措施。方法对我院2018年全年出院病案进行抽查,共计4 652份,由从事病案编码工作10年以上的编码人员注意检查病案首页数据中存在的错误情况,分析错误原因并提出改进措施。结果 4 652份病案中,出现编码错误有406份,编码错误发生率为8.73%;编码错误发生情况有疾病选择错误、合并症编码错误、未按病理报告编码错误、病案首页项目不完整、死亡证明卡编码错误、未应用合并编码原则错误,其中错误率最高的是疾病选择错误,占比26.85%;406份编码错误病案原因分析,主要原因为未按照ICD-10编码原则错误、临床医师书写错误、临床医师书写不规范错误、临床医师漏填、编码摘录错误和系统问题,其中ICD-10编码原则错误发生率高35.47%,其次为临床医师书写错误16.01%。结论医院病案首页数据编码错误的原因主要是临床医师书写不规范、编码人员素质不高有关,需要临床加强对临床医师及编码人员专业内容培训,不断提高医院病案首页编码质量。

Objective To analyze the coding of medical records on the first page of hospital medical records and improve measures. Methods Random checks were conducted on discharged medical records in our hospital in 2018, a total of 4 652 copies were collected. Coders who have been engaged in medical record coding for more than 10 years should pay attention to the errors in the data on the first page of medical records, analyze the causes of the errors and propose improvement measures. Results Among 4 652 medical records, there were 406 cases of coding errors, and the rate of coding errors was 8.73%;the cases of coding errors included disease selection errors, comorbid coding errors, coding errors not according to pathology report, incomplete medical record homepage items, and death Prove that the card is incorrectly coded and the combined coding principle is not applied. The highest error rate is disease selection error, accounting for 26.85%;406 cases of coding error medical records are analyzed, mainly due to errors not in accordance with ICD-10 coding principles and written by clinicians Errors, clinicians’ irregular writing errors, clinicians’ omissions, coding excerpt errors, and system problems. Among them, the ICD-10 coding principle error rate was 35.47% higher, followed by clinicians’ writing errors 16.01%. Conclusion The main reasons for the coding errors in the first page of hospital medical records are the irregular writing of clinicians and the low quality of coding staff. It is necessary to strengthen the professional content training of clinicians and coding personnel in clinics to continuously improve the coding quality of the first page of hospital medical records.