云南省某院病案首页诊断及手术操作编码质量分析

Analysis on the quality of the first page diagnosis and operation code of a hospital in Yunnan Province

目的 分析病案首页诊断及手术操作编码质量,提高病案首页编码正确率。方法 抽取某院2020年11月1日-2020年11月30日按照出院时间顺序前200份出院病案,按自查相关要求进行病案首页质量自查。结果 200份病案中,报送主要诊断编码正确率94.00%,医师填写诊断及手术操作正确率79.00%,常见问题为:主要诊断选择错误12份、其他诊断选择错误6份、漏填4份、多填3份;主要手术操作选择错误3份,其他手术操作选择错误2份、漏填4份,多填4份,其他问题24份;编码员编码正确率87.50%,主要问题为:主要诊断编码错误12份、其他诊断编码错误10份、主要手术操作编码错误3份、其他编码问题4份。结论 病案首页疾病及手术操作编码质量有待进一步提高,医院应建立健全病案首页质量控制常态化工作机制,提高病案首页主要诊断编码正确率。

Objectives To explore the measures to improve the quality of the front page of medical records and improve the accuracy of the main diagnostic codes of the front page of medical records.Methods According to the relevant requirements of this self-examination,the first 200 discharged medical records of a hospital in November 2020 were selected to carry out the self-examination of the quality of the first page of medical records from April 25 th to May 12 th,2021.Results Among the 200 medical records,12 were wrong in main diagnosis,6 were wrong in other diagnosis,4 were missed,3 were over filled,3 were wrong in main operation,2 were wrong in other operation,4 were missed,4 were over filled and 24 were other problems;The main problems of cataloging included 12 main diagnosis coding errors,10 other diagnosis coding errors,3 main operation coding errors and 4 other coding problems;188 medical records with correct main diagnosis codes were submitted,158 medical records were filled in by doctors,175 medical records were coded by coders.The correct rate of main diagnosis codes submitted was 94.00%,and the accuracy rate of diagnosis and operation filled in by doctors was 79.00% and 87.50% by coders.Conclusions It was expected to improve the accuracy of the main diagnostic codes of the front pages of medical records by establishing and improving the normalization mechanism of the quality control of the front pages of medical records.