120份肺炎的编码质量分析

An analysis of coding quality of 120 cases of pneumonia

目的分析某院120份首页主要诊断为肺炎的疾病编码情况,总结分析编码错误原因,从而提高肺炎编码质量,为国家三级公立医院绩效考核肺炎单病种管理准确监测数据奠定基础,更好顺应医保按病种分值付费方式(DIP)。方法使用某院病案管理系统检索2021年1月1日—2022年8月31日主要诊断编码类目为肺炎J12-J18的病案共2257份,随机抽取其中120份,重新审核每份病案肺炎编码情况。结果复核120份病案中,编码错误合计18份,编码错误率为15%。其中医师填写不规范,编码员随错13份;医师填写不规范,编码员修正后仍错误2份;医师填写正确,编码员编错3份。结论肺炎的临床诊断书写习惯与ICD-10分类轴心不同,错误率高,通过加强临床医师ICD-10编码培训,规范临床医师使用诊断名称,加强编码员临床知识及专业知识的培训,建立三级编码质控模式,进而提高肺炎编码正确率。

Objective To analyze the coding situation of 120 diseases mainly diagnosed with pneumonia on the homepage of a hospital and summarize the reasons for coding errors,so as to improve the quality of pneumonia coding,lay the foundation for accurate monitoring data of pneumonia single disease management in performance evaluation of national tertiary public hospitals,and better comply with the medical insurance payment method based on disease classification(DIP).Methods A total of 2257 records of pneumonia were retrieved from the main diagnostic code from January 1 st,2021 to August 31 st,2022 by using a hospital medical record management system.120 of them were selected by random sampling,and the pneumonia code of each medical record was re-examined.Results Out of 120 medical records reviewed,a total of 18 were coding errors,with a coding error rate of 15%.The clinician’s filling was not standardized,and the coder made 13 mistakes;the clinician’s filling was not standardized,and the coder still made two errors after correction;the clinician filled in correctly,and the coder made three mistakes.Conclusion The writing habit of clinical diagnosis of pneumonia was different from the ICD-10 code name,with a high error rate.By strengthening the training of clinicians on ICD-10 coding,standardizing the use of diagnostic names by clinicians,strengthening the training of coders on clinical knowledge and professional knowledge,establishing a two-way communication channel between coders and clinicians,and establishing a three-level coding quality control model,the accuracy of pneumonia coding can be improved.