医院病案首页数据病案编码情况及改进措施分析

Analysis of Case Coding Situation and Improvement Measures in Hospital Case Home Page Data

目的:分析医院病案首页数据,整理其编码情况并就改进措施进行研究。方法:选取2022年1—12月喀什地区第一人民医院病案室的2651份出院病案进行研究,开展编码检查,整理疾病编码错误类型、错误发生原因以及各系统疾病分布情况,从而制定有效的改进措施。结果:2651份出院病案有263份存在编码错误的情况(9.92%),以主要与次要诊断选择错误(31.18%)占比最高;错误发生原因包括医师书写有误(15.59%)、未根据国际疾病分类(ICD)-10编码原则(34.60%)、书写方式不规范(18.25%)、未区分先天性与后天性疾病(5.70%)、损伤类型不明确(4.56%)、编码摘录有误(11.03%)、未区分年龄区间(9.13%)与其他(1.14%);疾病编码错误各系统疾病分布情况以恶性肿瘤(24.71%)占比最高,其次为心血管疾病(14.45%)、妇科系统疾病(12.55%)、血液恶性疾病(10.65%)。结论:针对医院在病案首页数据中病案编码存在的问题,需采取强化病案书写的培训、加强编码人员团队建设、搭建ICD-10系统、增强专项质控、加快信息化建设、制定规律的编码任务、相对固定科室编码等措施,以提高主要诊断和疾病编码的准确性,确保医院病案首页的整体质量。

Objective:To analyze the hospital case home page data,organize its coding situation and conduct research on improvement measures.Methods:Two thousand six hundred and fifty-one discharged cases from the case room of Kashi First People's Hospital from January to December 2022 were selected for the study to carry out coding inspection,to organize the types of disease coding errors,the reasons for the occurrence of the errors,and the distribution of diseases in various systems,so as to formulate effective measures for improvement.Results:There were two hundred and sixty-three of the two thousand six hundred and fifty-one discharged cases with coding errors(9.92%),with the highest percentage of errors in the selection of primary and secondary diagnoses(31.18%);reasons for the errors included errors in physician writing(15.59%),failure to code according to International Classification of Diseases(ICD)-10 coding principles(34.60%),irregular writing style(18.25%),failure to differentiate between congenital and acquired diseases(5.70%),unclear type of injury(4.56%),incorrect coding excerpts(11.03%),and failure to differentiate between age range(9.13%)and other(1.14%);the distribution of disease coding errors by system was highest for malignant neoplasms(24.71%),followed by cardiovascular diseases(14.45%),gynecological system diseases(12.55%),and hematologic malignant diseases(10.65%).Conclusion:To address the problems of case coding in hospitals in the case home page data,measures need to be taken to strengthen the training of case writing,enhance the team building of coding staff,build the ICD-10 system,enhance the special quality control,speed up the construction of information technology,develop regular coding tasks,and relatively fix the coding of departments to improve the accuracy of coding of the main diagnoses and diseases and to ensure the overall quality of the case home page in hospitals.