某医院2021年住院病案首页ICD编码质量分析

doi:10.3969/j.issn.1006-5253.2022.03.005

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Abstract Objective To analyze the ICD coding errors on the first page of inpatient medical records in a hospital in 2021, find out the causes of coding errors, and put forward continuous improvement measures to improve the quality of ICD-coding.Methods According to the filling requirements of disease diagnosis and surgery or operation in the filling specification of medical security fund settlement list, the quality control personnel of each department carried out preliminary quality control for the medical records. After the medical records were filed, the medical record coder carried out secondary quality control. Finally, the senior coding quality control personnel reviewed and summarized the ICD coding errors of each department from January 1, 2021 to December 31, 2021, and recorded the distribution of coding error categories.Results In 2021, there were 10 860 medical records of discharged patients in each clinical department, with 1 710 wrong coding medical records, and the coding error rate was 15.75%; the proportion of major diagnostic coding errors (wrong coding, inconsistent with core treatment, inconsistent with main surgery or operation) was 8.53%; the proportion of other diagnostic coding errors (wrong coding, overstatement of other diagnosis, omission of other diagnosis) was 52.28%; the proportion of major surgery or operation coding errors (name filling error, omission, wrong coding, not corresponding to the main diagnosis) was 2.16%; other surgery or operation coding errors (wrong coding, over filling and missing) accounted for 37.02%.Conclusion Hospital management, doctors and coders all have important impacts on the quality of ICD coding. Through continuous improvement measures, such as establishing DRG operation mechanism, carrying out bidirectional training regularly, and perfecting electronic medical record coding verification function, the error rate of ICD coding can be reduced.

Key words： the first page of medical records ICD coding quality coding error

Received: 14 March 2022

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Shen Min. ICD coding quality analysis of the first page of inpatient medical records in a hospital in 2021[J]. journal1, 2022, 29(3): 183-187.

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http://manu58.magtech.com.cn/Jwk_zgyytj/EN/10.3969/j.issn.1006-5253.2022.03.005 OR http://manu58.magtech.com.cn/Jwk_zgyytj/EN/Y2022/V29/I3/183

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