205份产科住院病案主要诊断选择及编码质量分析

Main diagnostic selection and coding quality analysis of 205 obstetric inpatient records

目的通过分析某医院产科住院病案主要诊断选择及编码存在的问题,旨在有针对性地提高产科主要诊断选择及编码质量。方法随机抽取某医院2024年1月1日—4月30日产科住院病案205份,由三位高年资编码员共同核查病案,利用查检表对错误情况进行汇总分析。结果在205份产科病案中主要诊断选择及编码错误72份,错误率达35.12%;其中临床医师选择错误编码员跟着错编55份,临床医师选择正确编码员错编或漏编13份,临床医师漏填主要诊断编码员漏编4份。结论产科的主要诊断选择及编码极其特殊,难度较大,应加强临床医师的培训,规范临床医师的书写,强化主要诊断选择的重要性;同时加强编码员的管理,规范编码操作流程,强化专业知识学习,提高专业储备,加强与临床医师的双向沟通,共同提升产科主要诊断选择及编码正确率,从而保证产科住院病案首页数据质量。

Objective By analyzing the main diagnostic choices of inpatient records in obstetrics and the problems existing in ICD codes,we can improve the quality of the main diagnostic choices and coding in obstetrics.Methods A total of 205 obstetric inpatient medical records were randomly selected from a hospital from January 1 to April 30,2024,and the medical records were checked jointly by three senior coders,and the errors were summarized and analyzed by using the check table.Results Among 205 obstetrical medical records,72(35.12%)were found to have errors in the selection and coding of major diagnoses;among them,there were 55 cases of incorrect selection by clinician and incorrect compilation by coders,13 cases of correct selection by clinician,incorrect compilation or omission by coders,4 cases of omission by clinician and omission by coders.Conclusion The selection and coding of the main diagnosis in obstetrics are very special and difficult,so the training of clinicians should be strengthened,the writing of clinicians should be standardized,and the importance of the main diagnosis selection should be strengthened.At the same time,strengthen the management of coders,standardize the coding operation process,strengthen the learning of professional knowledge,improve professional reserves,strengthen the two-way communication with clinicians,and jointly improve the main diagnosis selection and coding accuracy rate of obstetrics,so as to ensure the quality of data on the first page of obstetric inpatient medical records.