摘要
目的分析住院病案首页疾病分类编码存在的问题及优化措施,以提高分类编码的准确率。方法回顾性分析2019年3月至2021年2月本院4000份住院病案的相关数据,其中2019年3月至2020年2月为干预前,共2000份病案;2020年3月至2021年2月为干预后,共2000份病案。对每份病案进行疾病分类编码审核,比较干预前后编码错误类型比例及编码错误发生率,以及统计干预前问题病案编码错误原因。结果干预后,病案总编码错误率为17.55%,低于干预前的42.10%,差异有统计学意义(P<0.05);干预前,病案总编码错误共842份,其中编码员部位编码混淆、编码员滥用残余类目、编码员编码不分型为干预前问题病案编码常见错误原因,占比分别为41.92%、26.72%、18.17%。结论针对医院病案首页疾病分类编码所出现的问题,可采用专业培训、医院信息化建设、质量控制等措施进行改善。
Objective To analyze the problems and optimization measures of disease classification and coding on the homepage of inpatient med-ical records,so as to improve the accuracy of classification and coding.Methods The data of 4000 copies in our hospital from March 2019 to Febru-ary 2021 were retrospectively analyzed,of which March 2019 to February 2020 was before the intervention,a total of 2000 medical records;March 2020 to 2021 In February,after the intervention,there were a total of 2,000 cases.Conduct disease classification and coding review for each medical record,and the proportion of coding error types and the total incidence of coding errors were compared before and after intervention,and the causes of wrong coding of problem medical records before intervention was statistics.Results After the intervention,the total coding error rate of medical records was 17.55%,which was lower than 42.10%before the intervention,and the difference was statistically significant(P<0.05).Before the inter-vention,there were 842 copies of total coding errors in medical records,among which the common causes of coding errors in problematic medical re-cords before the intervention were the confusion of coding parts,the abuse of residual categories by coders,and the untimely coding of coders,ac-counting for 41.92%,26.72%and 18.17%respectively.Conclusion Aiming at the problems of disease classification and coding on the homepage of hospital medical records,measures such as professional training,hospital information construction and quality control can be taken to improve them.
作者
苏彩霞
吴淑女
SU Caixia;WU Shunv(Medical Case Room of Xiamen Haicang Hospital,Xiamen,Fujian,361026,China)
出处
《当代医学》
2022年第22期103-105,共3页
Contemporary Medicine
关键词
住院病案
疾病分类编码
优化措施分析
编码错误
Inpatient medical record
Classification and coding of diseases
Analysis of optimization measures
Coding error
