某市2021年住院病案首页主要诊断缺陷情况分析

Analysis of Main Diagnosis Defects on the Front Page of Medical Records in a City in 2021

目的分析主要诊断出现错误的情况,规范主要诊断选择,提高住院病案首页质量。方法采用回顾性调查分析,由该市病案质控中心专家组成员,抽查该市19家三级公立医疗机构2021年住院病案首页,每家医疗机构随机抽取6月1日当日出院病案30份,合计570份,对存在缺陷的住院病案首页进行问题分类,利用卡方检验进行统计分析。结果570份住院病案首页的主要诊断合格率70.35%,其中主要诊断缺陷情况主要集中在呼吸内科、肿瘤内科及消化内科;主要诊断选择错误151份,错误率为26.49%,其中由于未选择正确的疾病发展阶段作为主要诊断而导致的错误最多,错误率为10.18%;主要诊断编码错误37份,错误率为6.49%,其中由于该合并编码的疾病未合并编码而导致错误的情况最多,错误率为3.33%;主要诊断选择错误是该市住院病案首页主要诊断缺陷的主要因素(P<0.05)。结论该市三级以上公立医疗机构对住院病案首页主要诊断选择相关知识欠缺,对主要诊断选择原则掌握不充分;编码员对于ICD合并编码相关知识掌握情况不佳;部分内科科室主要诊断错误率较高;应当加强临床医师及编码员针对主要诊断选择相关知识培训工作、组织编码员有针对性的学习相关编码知识以及加强住院病案首页质量管理工作。

Objectives To analyze the errors of main diagnosis,standardize the selection of main diagnosis,and improve the quality of the first page of inpatient medical records.Methods To use retrospective investigation and analysis,the members of the expert group of the city's medical record quality control center adopted the method of random sampling to spot check the main diagnosis selection on the front page of inpatient medical records of 19public medical institutions above tertiary hospitals in the city on June 1st,2021,and randomly selected 30 Medical records discharged on June 1st from each medical institution,a total of 570,classify the problems on the front page of the defective medical records,and use the chi square test of single factor analysis for statistical analysis.Results The main diagnostic qualification rate of 570 inpatient medical records was 70.35%;The main diagnostic defects were mainly in respiratory medicine,oncology medicine and digestive medicine;151 main diagnosis errors were selected,the error rate was 26.49%,of which the most errors were caused by not selecting the correct disease development stage as the main diagnosis,the error rate was 10.18%;There were 37 errors in the main diagnostic codes,with an error rate of 6.49%,among which the most errors were caused by the combined coding of diseases without combined coding,with an error rate of 3.33%;The results of univariate analysis showed that the main diagnostic selection error was the main factor leading to the main diagnostic defects on the first page of medical records in the city(P<0.05).Conclusions Public medical institutions above tertiary hospitals in the city lacked knowledge of the main diagnosis selection on the front page of inpatient medical records and had insufficient grasp of the main diagnosis selection principles.Coders had poor knowledge of ICD combined coding;The main diagnostic error rate of some internal medicine departments was higher.It was necessary to strengthen the training of clinicians and coders in selecting relevant knowledge for major diagnoses,organize coders to learn relevant coding knowledge in a targeted way,and strengthen the quality management of the first page of inpatient medical records。