某三甲医院2042份消化内科疾病与手术编码质量分析

Quality ofgastroenterology disease and surgical coding for2 042 cases from a tertiary hospital

目的 通过对某三甲医院2022年所有住院病案中的消化内科的疾病与手术的编码进回顾性研究,了解消化内科病案首页疾病与手术编码存在的问题,以有针对性地提高编码质量。方法 通过病案录入系统调取某三甲医院2022年消化内科的病案共2 042份,由两位编码员以及一位主诊医生共同核查病案,对错误编码情况及错误原因进行归类、统计和分析,并提出改进措施。结果 在2 042份病案中发现主要诊断选择及编码错误39份,其他诊断编码错误99份,病理诊断编码错误4份,损伤及中毒外因诊断错误2份,主要手术选择及编码错误14份,其他手术编码错误25份。结论 消化内科疾病与手术编码专业性强,对需要掌握的临床知识要求高,需要编码员与临床医师有高度的责任心与耐心,应加强对编码员与临床医师的培训力度,充分发挥信息系统的监督控制功能,通过多部门协作来提高编码准确性,保证住院病案首页数据的质量。

Objective To investigate the quality of the disease and surgical coding of all inpatient medical records in the gastroenterology department of a tertiary hospital in 2022 so as to identify the problems in the coding of diseases and surgeries on the front page of gastroenterology medical records and improve the quality of coding.Methods A total of 2042 medical records from the gastroenterology department in 2022 were collected through the medical records entry system.Two coders and one attending doctor jointly reviewed the medical records,classified,statistically analyzed the coding errors and their causes,and proposed improvement measures.Results Among the 2042 cases,39 had major diagnostic selection and coding errors,99 had other diagnostic coding errors,4 had pathological diagnosis and coding errors,2 had external causes of injury and poisoning diagnosis errors,14 had major surgical selection and coding errors,and 25 had other surgical coding errors.Conclusion The coding ofdiseases and surgery in gastroenterology is highly professionalized for a high level of clinical knowledge,which requires coders and clinicians to have a high sense of responsibility and patience.Strengthening the training of coders and clinicians,fully utilizing the information system’s supervisory control function,and enhancing multi-departmental collaboration can improve coding accuracy and ensure the quality of the inpatient medical records front page data.