[1]李增芳,丁松瑞,赵 敏,等.公立医院绩效考核背景下某医院病历档案首页常见问题分析[J].医学信息,2020,33(22):145-146.[doi:10.3969/j.issn.1006-1959.2020.22.041]
　LI Zeng-fang,DING Song-rui,ZHAO Min,et al.Analysis of Common Problems on the First Page of Medical Records of a Hospital Under the Background of Performance Assessment in Public Hospitals[J].Medical Information,2020,33(22):145-146.[doi:10.3969/j.issn.1006-1959.2020.22.041]
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公立医院绩效考核背景下某医院病历档案首页常见问题分析()
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医学信息[ISSN:1006-1959/CN:61-1278/R]

卷:
33卷
期数:
2020年22期
页码:
145-146
栏目:
调查分析
出版日期:
2020-11-15

文章信息/Info

Title:
Analysis of Common Problems on the First Page of Medical Records of a Hospital Under the Background of Performance Assessment in Public Hospitals
文章编号:
1006-1959（2020）22-0145-02
作者:
李增芳; 丁松瑞; 赵 敏; 等
（昆明医科大学第三附属医院/云南省肿瘤医院/云南省癌症中心，云南 昆明 650118）
Author(s):
LI Zeng-fang; DING Song-rui; ZHAO Min; et al
(The Third Affiliated Hospital of Kunming Medical University/Yunnan Cancer Hospital/Yunnan Cancer Center,Kunming 650118,Yunnan,China）
关键词:
医院绩效考核; ICD编码; 病历档案
Keywords:
Hospital performance appraisal; ICD code; Medical record file
分类号:
R197
DOI:
10.3969/j.issn.1006-1959.2020.22.041
文献标志码:
A
摘要:
目的 了解某医院病案首页填报现状，探究病案首页的重要性。方法 通过案例分析法，回顾总结某医院2019年1~12月98264例患者病案首页质控中存在的问题。结果 某医院的病案首页填写存在不足，ICD-10疾病编码和ICD-9手术及操作编码也存在明显不足，其中疾病编码选择错误最多，为16.92%，其次为主要诊断选择错误，占15.07%。结论 针对病案首页填写疾病与手术操作 ICD 编码缺陷等情况，应采取多举措提高病历档案质量，保证填写的准确性与完整性。在医院、临床医生、病案管理科编码人员共同努力下做好病案首页填写工作。
Abstract:
Objective In order to understand the status on the first page of medical records and explore the importance on the first page of medical records.Methods Via case analysis method,the common problems in the first page of medical records of 98264 patients from January to December 2019 were reviewed and summarized.Results There is obvious deficiency in filling in the first page of medical records in the hospital.The ICD-10 disease code and the ICD-9 surgery and operation code are also significantly inadequate. Disease coding error accounted for 16.92%, followed by major diagnostic error accounting for 15.07%.Conclusions According to the status of filling in problems on the first page of medical records, diseases and surgical operations ICD coding defects, a hospital has taken many measures to improve the quality of medical records and ensure the accuracy and completeness of filling in records.Only with the joint efforts of clinicians and coders of the medical record management department,the writing first page of medical records can be done well.

参考文献/References:

[1]伍凤兰,申勇.公立医院改革--历史演进、制度困境与路径选择[J].中国卫生政策研究,2015,9(1):34-39. [2]廖慧群,麦紫娟.基于绩效考核为导向的住院病案首页填写培训效果评价[J].中国病案,2020,21(5):9-12. [3]郝智慧,赵彩霞.浅谈住院病案首页存在的缺陷及防范对策[C]//第二十八届中国医院协会病案专业委员会学术会议.2016.[4]简少玲.在病案信息管理中发现的问题及改进建议[C]//中国医院协会病案管理专业委员会学术会议.2014.[5]苏云霞,于莉莉.以阑尾炎为例分析按病种付费条件下的疾病分类质量[J].实用医药杂志,2020,37(2):187-190. [6]朱晓荣.住院病案首页离院方式填写质量分析及对策[J].中国病案,2017,18(8):6-8.

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更新日期/Last Update: 1900-01-01