产科住院病案首页主要诊断质量分析

Quality Analysis of Main Diagnosis of the First Page of Obstetric Medical Records

目的查阅某院产科出院病案首页主要诊断情况,进行统计分析并找出影响因素,进而提高产科住院病案首页主要诊断质量。方法对该院2020年1月1日-2020年12月31日产科出院的5359份病案进行主要诊断审核,筛选出存在错误的1303份病案进行统计分析。结果1303份问题病案中,存在主要诊断选择错误的有1108份,占85.03%;存在主要诊断编码错编的有195份,占14.97%。主要诊断选择错误类型有4类,单胎顺产占31.32%、剖宫分娩占27.89%、单胎活产占22.11%,确认妊娠占18.68%;主要诊断编码错误主要体现在4类疾病,妊娠糖尿病占26.15%、胎膜早破占22.05%、瘢痕子宫占16.92%、胎儿宫内窘迫占15.90%,累计构成比为81.03%。结论强化规范填写住院病案首页主要诊断的培训、提高病案编码员专业技术水平、加强住院病案首页主要诊断质量的监管与考核是提高住院病案首页主要诊断质量的主要措施。

Objective To improve the main diagnostic qualityof the first page of medical records,the main diagnosis of obstetrics department in a hospital were inspected.Methods From January 1,to December 31,2020,the main diagnosis of 5359 medical records from the obstetrics department was checked,1303 medical records with errors were screened out.Results There were 1108 medical records of wrong choice of main diagnosis,which were accounting for 85.03%.There were 195 medical records of wrong main diagnostic code,which were accounting for 14.97%.There were four main types of diagnostic selection errors,Single Spontaneous Delivery(31.32%),Delivery by Caesarean Section(27.89%),Single Live Birth(22.11%),Pregnancy Confirmed(18.68%).The main diagnostic coding errors were mainly reflected in four types of diseases,Diabetes Mellitus in Pregnancy(26.15%),Premature Rupture of Membranes(22.05%),Scarred Uterus(16.92%),Fetal Distress(15.90%),andthe cumulative constituent ratio of these four diseases were accountingfor 81.03%.Conclusions As result of that,hospitals should strengthen the training of main diagnosis filling in the first page of medical records,improve the professional and technical level of medical record coders,and strengthen the supervision and assessment of the first page of medical records.