深圳市某三级医院病案首页诊断及编码缺陷分析

Diagnostic and coding errors on the first page of medical records from a tertiary hospital in Shenzhen

目的分析某三级医院病案首页诊断及编码的缺陷并探讨相应的解决措施,提高住院病案首页填写质量。方法采用回顾性分析法,调取深圳市某三级医院2023年1—12月病历首页的质控数据及编码的逻辑校对数据,并将研究数据归纳分析。结果共463项缺陷,其中主要诊断选择错误99项,构成比为21.37%,主要手术操作选择错误148项,构成比为32.00%,漏其他诊断33项,构成比为7.12%,漏手术操作121项,构成比为26.12%。主要诊断选择错误原因中,未选择病因作为主要诊断的病案占比最高,共24项,占比24.24%,其次为主要诊断笼统15项,占比15.15%。编码错误共169项,其中编码逻辑错误占比最高,共61项,占比36.09%,其次是漏编码,共58项,占比34.33%,该合并编码未合并,共30项,占比17.75%。结论目前医院病案首页仍存在一定的不足,应该加强对临床医师及编码员培训,加强医院首页的智能化信息化质量控制,提高住院病案首页的管理质量。

Objective To analyze flaws in diagnosis and coding of diseases on the first pages of inpatient medical records and explore solutions to improve the accuracy of record-filling in tertiary hospitals.Methods A retrospective analysis was conducted to assess the quality control and logical verification data from the first pages of inpatient records at a tertiary hospital,collected from January to December 2023.Results A total of 463 flaws were identified,including 99 flaws in primary diagnostic selection,accounting for 21.37%,148 flaws in primary surgical selection accounting for 32.00%,33 omissions in secondary diagnoses,accounting for 7.12%,and 121 omissions in surgical procedures accounting for 26.12%.Primary diagnostic errors were primarily attributed to failure to specify etiology,with the highest number of 24 cases(24.24%),followed by overgeneralized diagnostic descriptions,with 15 cases(15.15%).Totally,169 coding errors were identified,including 61 logic errors(36.09%),58 coding omissions(34.33%),and 30 uncombined coding cases(17.75%).Conclusion There are significant flaws in the coding on the first pages of medical records.It is imperative to strengthen the training for clinicians and coders and enhance quality control through intelligent automation.These measures are crucial for improving the quality control of the first pages of medical records.