2021年广东省主要诊断编码正确率基线调查

Baseline Survey and Analysis of the Accuracy of Main Diagnostic Codes in Guangdong Province in 2021

目的通过对广东省主要诊断编码正确率基线调查分析,了解广东省主要诊断编码填写现状,探讨提高主要诊断编码正确率的改进路径及相关措施。方法广东省病案质控中心于2021年5月组织评审专家利用国家病案质控中心制定的调查表,对省内12个地市24家医院共960份病案开展主要诊断编码正确率调查。结果抽查医院主要诊断编码正确率为82.92%,主要诊断填写正确率79.58%。问题病案中临床填写有问题,经编码员调整后正确上报的占34.14%,编码员未作调整导致数据错误上报的占33.74%,编码员调整后仍然上报错误的占10.84%,临床填写正确,单纯编码错误的占比21.29%。不同级别医院问题病案原因分布差异明显。主要诊断编码错误率较高的章节为循环系统疾病、妊娠分娩产褥期和损伤、中毒和外因的某些其他后果;临床填写错误率最高的是影响健康状态和健康机构接触的因素、循环系统疾病和肿瘤。结论广东省病案数据基础质量较好,但不同等级医院间数据质量差距明显,临床填写习惯及编码人员核查是主要诊断编码正确率的重要影响因素,应加强临床医师专项培训及编码专业队伍建设,完善数据宏观管理体系及信息系统建设。

Objectives This study investigated and analyzed the current situation of the main diagnostic coding accuracy in Guangdong Province,in order to explore the approaches of improvement and related measures.Methods In May 2021,Guangdong Medical Records Quality Control Center organized evaluation experts to investigate the accuracy of main diagnostic codes in 960 medical records from 24 hospitals in 12 cities in Guangdong province by using the questionnaire developed by National Medical Records Quality Control Center.Results The correct rate of main diagnosis codes was 82.92%,and the correct rate of main diagnosis was 79.58%.Among those incorrect medical records,34.14%was adjusted and correctly reported by the coders,33.74%was not adjusted and incorrectly reported by the coders,10.84%was adjusted but still incorrectly reported by the coders,and 21.29%was correct in clinical filling but incorrect in coding.The cause distribution of medical record problems in different levels of hospitals is considerably different.The major diagnostic codes with high error rates were circulatory diseases,pregnancy,childbirth and puerperium,injuries,poisoning and some other consequences of external causes.The highest clinical error rates were found in factors affecting health status and health institution contact,circulatory diseases and tumors.Conclusions The basic quality of medical record data in Guangdong province is good,but data quality gap between different grade hospitals,clinical fill in habits and coder verification are the important factors affecting the main diagnostic code accuracy.Hospitals should pay further attention to the special training of clinical doctors and the construction of professional coding team,in order to improve data management system and information system construction.