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目的对某院病案编码的质量进行监测,分析错误原因并提出整改措施。方法采用系统抽样法对2016年1月-6月的全院出院病案进行抽样,核查疾病和手术编码的情况,并进行逐一归类与分析。结果2016年上半年该院编码员每日病案编码数量人均110份左右,每月25日后编码的病案数占全月病案数的比例均高于40%。抽查9370份出院病案中,编码错误的病案为578份,占6.17%,错误率呈逐渐下降的趋势。在所有病案编码缺陷中,疾病诊断的错编所占比例最高,为55.24%,其次为手术的错编,为30.66%。病案漏编的情况主要为漏编手术操作中的另编码、疾病的肿瘤形态学编码及分娩结局,分别占41.86%、31.80%。根据统计发现造成病案错编的主要原因为编码员编码知识缺陷,占49.04%。结论加强编码员的培训和学习、规范临床医师的书写习惯,充分利用病案编码系统以确保病案编码的准确性。
Objective To monitor the quality of medical records in a hospital, analyze the causes of errors and propose corrective measures. Methods Systematic sampling method was used to sample hospital discharge cases from January to June in 2016, to check the disease and surgical coding, and to conduct classification and analysis one by one. Results In the first half of 2016, the code number of hospital coders per day was about 110 per capita. The number of case codes coded after the 25th of each month accounted for more than 40% of the total number of case records in the first half of 2016. Of the 9,370 random medical records, 578 cases were coded incorrectly, accounting for 6.17%. The error rate showed a gradual downward trend. In all cases of coding defects, the highest proportion of misdiagnosis of the disease diagnosis was 55.24%, followed by the wrong order of surgery was 30.66%. Leakage cases mainly for the missed coding operation in the other code, the disease morphology of the tumor coding and delivery outcomes, accounting for 41.86%, 31.80%. According to statistics, the main reason for the wrong coding of medical records was that the coder coded the knowledge defects, accounting for 49.04%. Conclusion Enhancing the training and learning of coders, standardizing the writing habits of clinicians, making full use of the medical record coding system to ensure the accuracy of the medical record coding.