病案归档及编码的流程优化措施及其效果评价

Process Optimization Measures and Effect Evaluation of Medical Record Filing and Coding

目的对病案归档及编码流程进行优化,提高病案首页编码质量,提升病案归档率,为DRGs医保付费开展提供保障。方法利用医院信息平台系统,抽取病案归档及编码流程优化前后病案数据,分别抽取2016年25 663份、2017年28 211份及2018年33 347份的第三季度病案首页信息数据,分析病案首页诊断编码数目少于医师诊断数目的病案比例,及病案归档率的变化。结果经归档及编码流程优化,病案首页诊断编码数目少于医师诊断数目的比例于2016年、2017年及2018年分别为:15.46%、3.55%和3.23%;漏编率3:7.4%,0.7%,0.23%;七日归档率3年分别为:96.21%、97.18%和100.00%;3日归档率2017年和2018年分别为25.42%及97.98%,且都具有统计学意义。结论病案归档及编码流程的优化提高了病案首页的编码质量,同时提高了病案的归档率,实施效果显著,具有借鉴意义。

Objective To optimize the filing and coding process of medical records,improve the quality of the homepage and filing rate of medical record,as well as provide guarantee for the payment of DRGs medical insurance.Methods Collected the data of medical records before and after the filing and coding process optimization by using the hospital information platform system,and analyzed the proportion of the number of medical records which the number of coded diagnoses on the homepage was less than the number of doctors’diagnoses,as well as the change of the filing rate.Results After filing and coding process optimization,the proportion of the number of medical records which the number of coded diagnoses on the homepage was less than the number of doctors’diagnoses was 15.46%,3.55%and 3.23%respectively in 2016,2017 and 2018.The leakage encoding rate was 7.4%,0.7%,0.23%for 3 years.The filing rate for 7 days was 96.21%,97.18%and 100.00%respectively for 3 years.In 2017 and 2018,the 3-day filing rate was 25.42%and 97.98%,respectively,the data were statistically significant.Conclusion The optimization of the filing and coding process of medical record improves the coding quality of the homepage of medical record,and at the same time,improves the filing rate of medical record.