“双循环”机制在提高住院病案首页主要诊断编码正确率中的应用

Application of"Double Cycle"Mechanism in Improving The Correct Rate of Main Diagnosis Code in The Front Page of Inpatient Medical Records

目的探讨“双循环”机制在提高住院病案首页主要诊断编码正确率中的应用,为有效提高主要诊断编码的正确率提供借鉴和参考。方法质控科牵头成立专家组,从病案系统中每月等距随机抽取15%的住院病案首页进行审核,其中2022年6月1日-2022年9月30日作为实施前组共计2347份,有手术及操作1241份,2022年10月1日-2023年5月31日为“双循环”机制实施后组共计6737份,有手术及操作3625份。审核结果由质控科整理汇总,比较干预前后主要诊断编码正确率、临床医师和编码员相关监测质量指标。采用SPSS22.0统计软件进行统计学处理,P<0.05表示差异有统计学意义。结果“双循环”机制实施后审核的6737份病案中,主要诊断编码正确6410份,正确率为95.15%,较实施前组的88.96%明显提高,差异具有统计学意义(P<0.05);实施后组医师主要诊断填写缺陷率由13.98%下降至3.34%(P<0.05),编码员主要诊断编码不精确缺陷率由6.69%下降至2.88%(P<0.05)。结论某院充分发挥“双循环”叠加效应,优化编码工作流程,使临床医师和编码员快速熟悉并掌握主要诊断选择原则,有效降低和防范人为缺陷的发生,从而逐步提高住院病案首页主要诊断选择及编码正确率,具有现实及可操作性。但在制度建设、流程再造上还存在欠缺,尚需在实践中进一步优化和完善。

Objectives This study aims to explore the application value of"double cycle"mechanism in improving the correct rate of main diagnostic codes on the front page of inpatient medical records,so as to provide a reference for effectively improving the correct rate of main diagnostic codes.Methods The Quality Control Department took the lead in establishing an expert group to randomly select 15%of the front pages of inpatient medical records from the medical record system every month for assessment.The period from June 1,2022 to September 30,2022 was selected as the pre-implementation group,with a total of 2347 cases,including 1241 surgeries and operations.The period from October 1,2022 to May 31,2023 was selected as the post-implementation group of the"double cycle"mechanism,with a total of 6737 cases,including 3625 surgeries and operations.The assessment results were summarized by the Quality Control Department.The main diagnostic coding accuracy rate and related monitoring quality indicators of clinicians and coders were compared before and after the intervention.SPSS22.0 statistical software was used for statistical processing,and P<0.05 indicated that the difference was statistically significant.Results After implementing the'double cycle'mechanism,out of the 6737 cases examined by the hospital,the main diagnosis code was correct in 6410 cases,yielding a correct rate of 95.15%.This rate is significantly higher than the 88.96%observed before implementation,with a statistically significant difference(P<0.05).After the implementation,the defect rate of doctors'main diagnosis filling decreased from 13.98%to 3.34%(P<0.05),and the defect rate of coders'main diagnosis coding inaccuracy decreased from 6.69%to 2.88%(P<0.05).Conclusions The hospital fully harnesses the'double cycle'superposition effect,optimizing the coding workflow.This enables clinicians and coders to quickly familiarize themselves with and master the main diagnosis selection principles,effectively reducing and preventing human errors.Consequently,it gradually improves the accuracy rate of main diagnosis coding on the front page of inpatient medical records,making it both realistic and feasible.However,there are still deficiencies in system construction and process reengineering that need further optimization and refinement in practice.