脑梗死主要诊断填写和编码质量分析

Completion and Coding Quality Analysis of the Main Diagnosis of Cerebral Infarction

目的 分析某三甲医院主要诊断为脑梗死的住院病案首页填写和ICD-10编码质量,以提高脑梗死疾病住院病案首页医师填写和编码员编码的准确率。方法 利用电子病案质控系统随机抽取某三甲医院神经科2020年6月10日-2021年8月31日医师填写住院病案首页主要诊断为脑梗死I63的600份住院病案。3名病案质控医师联合神经科主诊医师,另由4名资深编码员对600份住院病案首页主要诊断为脑梗死进行填报和编码质量检查,将研究数据利用Excel表描述统计法进行归纳分析。结果 600份病案中488份住院病案首页主诊医师填写正确,编码员完全按照医师正确填写进行正确编码488份,医师填写准确率为81.34%。112份病案医师填写错误,其中笼统诊断脑梗死66份,医师填写错误率58.93%,编码同错53份,编码员阅读病历正确编码13份,修正率11.6%;医师填写主要诊断栓子来源错误28份,错误率25%,编码同错22份,编码正确6份,修正率5.35%;医师填写责任血管错误18份,医师填写错误率16.07%,编码同错14份,编码正确4份,修正率3.57%。结论 脑梗死主要诊断编码质量受医师填写质量影响,编码员依赖性强,多直接按照临床医师的填写结果给予相应的编码。住院病案首页主要诊断脑梗死填写易出现笼统诊断,编码员对神经科知识掌握更加薄弱,加强医师与编码员培训工作,增强工作责任心,建立双方有效沟通,确保脑梗死患者住院病案首页医师填写与编码质量同步提高。

Objectives This study aims to analyze the front-page filling and ICD-10 coding quality of inpatient medical records mainly diagnosed as cerebral infarction in a tertiary hospital so as to improve the filling of inpatient medical record front pages by physicians and the coding accuracy of the coders.Methods The electronic medical record quality control system was used to randomly select 600 inpatient medical records mainly diagnosed as cerebral infarction I63 in the neurology department of a tertiary hospital from June 10, 2020 to August 31, 2021.Three medical record quality control physicians with neurology attending physicians, and four senior coders completed the reporting and coding quality inspection of 600 inpatient medical records with the main diagnosis of cerebral infarction on the front page.Excel table descriptive statistics method was used to perform inductive analysis of research data. Results 488 of the 600 medical records were filled in correctly by the attending physician on the medical record front pages. 488 medical records were filled correctly by the coder according to the correct filling by the physicians.The accuracy rate of physician filling was 81.34%.112 medical records were filled with errors by physicians, of which 66 were generally diagnosed with cerebral infarction.The error rate of physicians filling in was 58.93%. 53 copies of the same coding were wrong, and 13 copies of medical records were correctly coded by the coders. The correction rate was 11.6%. 28 medical records were filled in with the wrong sources of emboli by the physicians in the primary diagnosis.The error rate was 25%. The coding was wrong in 22 copies. The coding was correct in 6 copies, and the correction rate was 5.35%. 18 medical records were filled in with errors in the offending vessels. The error rate was 16.07%. The coding was wrong in 14 copies. The coding was correct in 4 copies, and the correction rate was 3.57%.Conclusions The quality of coding for the main diagnosis of cerebral infarction was affected by the quality of filling by physicians. The coders were highly dependent, and the corresponding coding was usually given directly according to the filling results of clinicians.The main diagnosis of cerebral infarction on the front page of inpatient medical records was prone to general diagnosis and coders had weak knowledge of neurology. The hospitals should strengthen the training of physicians and coders, increase work responsibility, and establish effective communication between the physicians and the coders in order to ensure the improvement of the filling quality and coding quality of the medical records with the main diagnosis of cerebral infarction on the front pages.