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目的探讨系统培训学习对病案编码质量的影响。方法将2015年10月-2016年9月培训学习后完成病案编码的出院病例作为研究组,将2014年9月-2015年8月培训学习前完成的病案编码的出院病例作为对照组,对比两组病例的疾病编码总条目数、统计病种数、残余类目数、手术操作病例数、手术操作总条目数。结果研究组的平均每出院人数编码条目数较对照组增加,统计病种数增加,其中残余类目条目数有明显下降,差异有明显统计学意义,研究组平均每出院人数手术操作编码条目数、手术操作编码的病例数明显高于对照组,操作编码增加明显,存在统计学差异。结论系统培训学习掌握编码基本原则是提高病案编码质量的有效方法和途径。
Objective To explore the impact of system training on the quality of medical records. Methods The discharged patients who completed the medical record after the completion of the training from October 2015 to September 2016 were selected as the research group and the discharged patients whose medical records were completed before September 2014 to August 2015 were selected as the control group. The total number of disease codes, the number of diseased species, the number of residual types, the number of surgical operations, and the total number of surgical operations in the group of patients. Results In the research group, the average number of code entries per hospital discharge increased compared with the control group, the number of statistical diseases increased, the number of residual category entries decreased significantly, the difference was statistically significant. The average number of codecs , The number of surgical operation coding was significantly higher than the control group, the operation code increased significantly, there is a statistical difference. Conclusion System training to master the basic principles of coding is to improve the quality of medical records an effective way and means.