心脏内科病案首页主要诊断填写质控效果分析

Analysis of Quality Control Effect of Diagnosis Filling in the First Page of Cardiology Medical Records

目的分析四川大学华西医院心脏内科病案首页主要诊断填写错误情况,逐步提高该科室病案首页主要诊断填写正确性。方法抽取四川大学华西医院2021年11月—2022年10月心脏内科出院病历共13796份,由同一位编码员对病案首页主要诊断填写的正确性进行判断,分析质控前后心脏内科病案首页主要诊断填写正确率的变化趋势。结果心脏内科病案首页主要诊断质控前6个月填写总错误率为43.8%,其中多个诊断填写为主要诊断占总病例数的29.8%,术后诊断填写为主要诊断占总病历数的9.8%,“大帽子”诊断填写为主要诊断和主要诊断选择错误分别占总病历数的2.3%和1.9%。质控措施实施后6个月总错误率为15.6%,各类错误占比分别为10.2%、2.3%、2.1%、1.0%。质控后心脏内科主要诊断填写错误率明显下降,差异有统计学意义(χ^(2)=1283.556,P<0.001)。结论质控前心内科主要诊断填写错误率较高,错误情况为将多个疾病诊断、术后诊断、“大帽子”诊断填写为主要诊断及主要诊断选择错误。采取质控措施后,主要诊断填写错误率明显下降。应制订病案首页主要诊断填写质控管理制度,持续推进主要诊断填写质控工作。

Objective To improve the correctness of main diagnosis filling on the first page of medical records in the department of Cardiology of West China Hospital of Sichuan University by analyzing the errors of main diagnosis filling on the first page of medical records.Methods A total of 13796 discharged cases from the Department of Cardiology of West China Hospital of Sichuan University from November 2021 to October 2022 were selected.The same coder judged the correctness of main diagnosis filling on the first page of medical records,and analyzed the changing trend of the accuracy of main diagnosis filling on the first page of cardiac records before and after quality control.Results The total error rate of filling in the main diagnosis in the first page of cardiac medical records was 43.8%in the 6 months before the quality control,among which,multiple diagnosis filling in the main diagnosis accounted for 29.8%of the total number of cases,postoperative diagnosis filling in the main diagnosis accounted for 9.8%of the total number of cases,"big hat"diagnosis filling in the main diagnosis and the main diagnosis selection error accounted for 2.3%and 1.9%of the total number of cases,respectively.Six months after the implementation of quality control measures,the total error rate was 15.6%,and all kinds of errors accounted for 10.2%,2.3%,2.1%and 1.0%,respectively.After quality control,the filling error rate of major diagnoses in the department of Cardiology was significantly decreased,and the difference was statistically significant(χ^(2)=1283.556,P<0.001).Conclusion Before quality control,the filling error rate of major diagnoses in the department of Cardiology was relatively high.The errors were that multiple disease diagnoses,postoperative diagnoses and"big hat"diagnoses were filled in as main diagnoses and the main diagnosis selection was wrong. After taking quality control measures, the error rate of filling in main diagnosis de creased significantly. The quality control management system of main diagnosis filling in the first page of medical re cords should be formulated, and the quality control work of main diagnosis filling should be continuously promoted.