Main diagnostic selection and coding quality analysis of 205 obstetric inpatient records
Objective By analyzing the main diagnostic choices of inpatient records in obstetrics and the problems exist-ing in ICD codes,we can improve the quality of the main diagnostic choices and coding in obstetrics.Methods A total of 205 obstetric inpatient medical records were randomly selected from a hospital from January 1 to April 30,2024,and the medical re-cords were checked jointly by three senior coders,and the errors were summarized and analyzed by using the check table.Results Among 205 obstetrical medical records,72(35.12％)were found to have errors in the selection and coding of major diagnoses;among them,there were 55 cases of incorrect selection by clinician and incorrect compilation by coders,13 cases of correct selection by clinician,incorrect compilation or omission by coders,4 cases of omission by clinician and omission by cod-ers.Conclusion The selection and coding of the main diagnosis in obstetrics are very special and difficult,so the training of cli-nicians should be strengthened,the writing of clinicians should be standardized,and the importance of the main diagnosis selec-tion should be strengthened.At the same time,strengthen the management of coders,standardize the coding operation process,strengthen the learning of professional knowledge,improve professional reserves,strengthen the two-way communication with cli-nicians,and jointly improve the main diagnosis selection and coding accuracy rate of obstetrics,so as to ensure the quality of data on the first page of obstetric inpatient medical records.
万方数据
维普
