Abstract：Objective To improve the accuracy of the main diagnosis and the coding of the main operations by summarizing and analyzing the main diagnosis and the coding of the main operations in the first page of the medical record of a general tertiary hospital.Methods Stratified sampling was used to select the first page of medical records of discharged patients in 10 specialties in the medical record management system of a tertiary hospital from April 2021 to April 2022, with surgery accounting for more than 30% of the total. The same cli-nicians and coders carried out the quality control of main diagnosis and surgical coding, and the linear trend chi-square test was used to analyze the change trend of the error rates of main diagnosis and main surgical procedures on the front page of medical records before and after quality control.Results Totally 1 400 medical records were collected and analyzed, of which 885 included operation. After one year of quality control for the main diagnosis and main surgical procedures, the error rate of the writing of the main diagnosis by clinicians reduced from 23.5% to 3.0%, and the error rate of the writing of the main diagnosis by coders reduced from 16.0% to 2.0%. The coding error rate of major surgical procedures reduced from 40.5% to 10.4%, with 19.0% decrease in the error rate of clinicians and 11.1% decrease in the error rate of coders.Conclusion The error rate of filling in and coding in the main diagnosis and main operations on the front page of the medical records is high, and the clinicians and the coders are the main responsible persons. It is necessary to strengthen the training and assessment of clinicians and coders, increase the verification of main diagnosis and surgical procedures in the information system, form a daily quality control plan and process, continue to promote the home page quality control work, and take the main diagnosis and main surgical procedures as the key quality control content.
何美玲，曾令霞. 住院病案首页主要诊断及主要手术操作编码持续性质控的效果分析[J]. 中国医院统计, 2022, 29(5): 362-366.
He Meiling，Zeng Lingxia. Effect analysis of continual quality control of main diagnosis and operation codes on the front page of inpatient medical records. journal1, 2022, 29(5): 362-366.
