基于某中医院病案首页疾病诊断及手术操作填写的质量分析
曾少婷1，李昕昊1，郭玉花1，梁燕霞2
1.深圳市宝安区中医院，广东 深圳 518000
2.南方医科大学深圳医院，广东 深圳 518000
第一作者：曾少婷（1981— ），女，本科，病案质控员，病案信息技术主管技师，主要研究方向为病案信息管理。联系电话：13500052795，E-mail：1093906374@qq.com
通讯作者：梁燕霞（1980— ），女，本科，病案信息技术主管技师，医保物价管理员，主要研究方向为病案信息管理。联系电话：13500052796，E-mail：763609331@qq.com
摘要：目的 对广东省深圳市某三甲中医院2022年出院住院病案首页进行抽查，核实临床医师及编码员填报疾病诊断（中医、西医诊断）、手术、操作（含中医治疗性操作）及编码（ICD和TCD）的准确性，分析其错误原因及类型，避免因其影响DRGs及DIP入组。方法 依据疾病的主要诊断、主要手术填写要求及选择原则，通过抽检的方式，分析2022年某中医院每月抽检的200份病案首页中包含死亡、转科、抢救、手术及操作等字样的病历的诊断、手术、操作的填写及编码等信息的核查，对其进行汇总分析。结果 从抽检的2400份病案中，有缺陷的诊断、手术、操作及编码共276份，占11.50%。检查出医师及编码员填写缺陷主要错误包括错选、漏填、多填和填写不规范。结论 通过具体原因分析，临床医师对主要诊断的选择及填写不规范是造成医师填报缺陷的主要原因，而编码员未熟练掌握编码规则及漏编是造成编码员填报缺陷的主要原因。须加强院科两级病案首页质量监控及ICD、TCD编码分类的质控，以进一步提高病案首页疾病诊断（中医、西医诊断）、手术、操作（含中医治疗性操作）及编码填写的质量。
关键词：主要诊断；手术操作；病案首页；编码(https://www.daowen.com)
Quality Analysis of Disease Diagnosis and Surgical Procedure Filling in the Medical Record Homepage of a Chinese Traditional Medicine Hospital
Zeng Shaoting1, Li Xinhao1, Guo Yuhua1, Liang Yanxia2
Shenzhen Bao’an Traditional Chinese Medicine Hospital, Shenzhen 518000, China
Abstract:Objective A spot check was conducted on the first page of the 2022 discharge medical records of a tertiary traditional Chinese medicine hospital in Shenzhen, Guangdong Province, to verify the accuracy of clinical physicians and coders in reporting disease diagnosis (traditional Chinese medicine, Western medicine diagnosis), surgery, procedures (including traditional Chinese medicine therapeutic procedures), and codes (ICD and TCD).The couses and types of errors were analyzed to avoid affecting DRGs and DIP enrollment.Methods Based on the main diagnosis of the disease, the requirements for filling in the main surgeries, and the selection principles, a sampling method was used to analyze the diagnosis, surgery, and procedure filling and coding verification of 200 medical records including death, transfer, rescue, surgery, and operation on the homepage of a certain Chinese medicine hospital collected every month in 2022, and to summarize and analyze them.Results The results showed that out of 2400 medical records sampled, a total of 276 cases had defective diagnoses, surgeries, procedures, and codes, accounting for 11.50%.The main errors identified by the physician and coder include incorrect selection, omission, overfilling, and non-standard filling.Conclusion Through specific cause analysis, the non-standard selection and filling of main diagnoses by clinical physicians are the main reasons for the defects in physician reporting, while the lack of proficiency in coding rules and omission of coding by coders are the main reasons for the defects in coding by coders.It is necessary to strengthen the quality monitoring of the first page of medical records at the hospital and department levels, as well as the quality control of ICD and TCD coding classification, in order to further improve the quality of disease diagnosis (traditional Chinese medicine, Western medicine diagnosis), surgery, procedures (including traditional Chinese medicine therapeutic procedures), and coding on the first page of medical records.
Keywords:Main diagnosis;Operation;First page of medical record;Code
2021年2月9日，国家卫生健康委发布了《2021年国家医疗质量安全改进目标》，其中目标六就是提高住院病案首页主要诊断编码正确率，这充分表明主要诊断编码的质量已上升至国家的医疗质量目标，主要诊断编码正确既需要医师按照规定，准确选择和规范填写住院病案首页中的主要诊断，同时又需要病案编码人员按照国家统一发布的疾病分类代码准确进行编码，然后按照统一的数据接口标准传送至国家相应的信息系统平台[1]。随着医疗卫生体制改革的深入，医疗管理工作的科学化、精细化、信息化程度不断提升，对病案编码质量的要求越来越高。不断提升住院病案诊断和手术操作编码质量，可为实行DIP、DRGs提供重要支撑，为开展公立医院绩效考核、推行医院精细化管理提供科学依据[2]。本文通过对广东省深圳市某三甲中医院2022年出院患者住院病案首页中抽取的诊断、手术/操作及编码填写质量进行分析，了解该院临床医师在填写病案首页的诊断、手术/操作及编码存在的问题，以进一步提高病案首页诊断、手术、操作及编码填写的质量。