论文部分内容阅读
目的通过对某院住院病案首页其他诊断(合并症和并发症)的填报进行质量分析,为有效提高病案首页完整性提供参考依据。方法抽取2013年-2015年3次病案质量督导检查共560份住院病案,将其他诊断填报错误按合并症和并发症分别归类,进行描述性统计。结果 2015年其他诊断填报错误比2013年明显减少,错误率由2013年14.50%降至2015年的3.75%;其他诊断中并发症填报错误共计13例,占比为2.32%;其他诊断中合并症填报错误共计31例,占比5.54%。结论医院提高对病案首页填报工作的重视,加强医师病案首页规范化培训,编码员努力学习医学专业知识以及利用DRGS工具加强医疗工作的绩效管理是提升病案首页填报质量的关键。
Objective To provide a reference for effectively improving the integrity of the first page of medical records through the quality analysis of other reports (complications and complications) of the first page of inpatient medical records of a hospital. METHODS: A total of 560 inpatient medical records were collected from 3 medical records quality supervision and inspection in 2013-2015, and the other diagnostic errors were classified according to the complication and complication, respectively, for descriptive statistics. Results In 2015, the number of misstatements in other diagnoses decreased significantly from 2013, and the error rate dropped from 14.50% in 2013 to 3.75% in 2015. In the other diagnoses, 13 cases were misrepresented, accounting for 2.32% of all other diagnoses. Other complications Report a total of 31 cases of error, accounting for 5.54%. Conclusion The hospital attaches great importance to the filing of the first page of the medical records, strengthening the standardization of the first page of the medical records, strengthening the coders’ medical knowledge and using the DRGS tools to improve the performance of medical work are the keys to improving the quality of the first page of medical records.