8398例手术级别填报情况分析

Analysis on the Filing Status of Surgical Complexity Levels in 8398 cases

目的 了解医院住院病案首页中手术级别错误情况,为医院提高手术级别正确率提供依据。方法 通过搜索2020年1月1日-2020年12月31日出院患者的住院病案首页信息库,共收集手术8398例,运用Excel 2010收集各科室手术级别填写情况,医师填写手术级别比实际级别高低差异情况和相同手术名称不同手术级别填写情况的数据资料,采用百分比N(%)或构成比进行描述性统计分析。结果 2020年该院手术级别错误总例数2140例,排名前5位的手术级别填写错误科室分别为骨科(42.99%)、泌尿外科(11.03%)、神经外科(9.39%)、普通外科(8.69%)、胸外科(7.02%)。手术级别比实际级别高662例,占30.93%,比实际级别低1478例,占60.07%。相同手术名称不同手术级别填写错误239例。结论 存在手术级别比实际级别高、相似或同名手术级别选择错误,需提高医师和病案管理人员对手术级别重视程度,并增加手术级别对照库,有效提高手术级别正确率。

Objectives This study aims to investigate the filing errors of surgical complexity levels on the inpatients’ medical record front pages in order to provide the basis for improving the accuracy of surgical complexity levels in the hospital. Methods 8398 cases of surgical operation were collected through screening the information database of the medical record front pages of discharged patients from January 1, 2020 to December 31, 2020. This study used Excel 2010 to collect the filing information of surgical complexity levels from each department, the difference between the filed surgical complexity levels and the actual situation and the difference in file surgical complexity levels of the same surgical type. Descriptive statistical analysis was performed using percentage n(%) or component ratio. Results 2140 cases in the hospital were filed with wrong surgical complexity levels in 2020. The top five departments with filing errors were orthopedics department(42.99%), urology department(11.03%),neurosurgery department(9.39%), general surgery department(8.69%), thoracic surgery(7.02%). 662 cases had surgical complexity levels higher than the actual levels, accounting for 30.93% of the total cases, while 1478cases had surgical complexity levels lower than the actual levels, accounting for 60.07%. 239 cases filed different surgical complexity levels for the same type of surgery. Conclusions This hospital should focus on training from certain perspectives, such as level 4 surgery, departments with filed surgical complexity levels higher than the actual levels or level selection of surgeries with similar or same names, starting from the departments filed more surgical complexity level errors. Meanwhile, doctors and medical record practitioner need to pay more attention to the surgical complexity level, and the hospital needs to increase the side of the comparison database of surgical complexity level in order to improve the accuracy of it.