基于病案信息技术对病案室编码准确率的影响

Influence of Medical Record Information Technology on the Accuracy of Medical Record Coding

目的探讨基于病案信息技术对病案室编码准确率的影响。方法选取2018年1月-2020年1月我院90份病案进行研究,其中2018年1月-2019年1月42份,2019年2月-2020年1月48份。于2019年2月将基于病案信息技术应用于病案室管理中,观察比较实施前后病案室编码准确率及病案质量评分。结果实施后编码准确率高于实施前(P<0.05)。实施后病案质量评分高于实施前(P<0.05)。结论基于病案信息技术可有效提高病案室编码准确率,对医院管理具有重要价值,值得推荐使用。

Objective To investigate the influence of medical record information technology on the accuracy of medical record coding.Methods 90 medical records of our hospital from January 2018 to January 2020 were enrolled, including 42 copies from January 2018 to January 2019 and 48 copies from February 2019 to January 2020.Medical record information technology was applied at February 2019,then the coding accuracy rate and quality score of medical records before and after implementation were compared.Results The coding accuracy rate was improved after implementation(P<0.05),and the quality score of medical records was also increased after implementation(P<0.05).Conclusion Application of medical record information technology can effectively improve the medical record coding, which has high application value in hospital management, so it is worthy of recommendation.