Practical Effect of Manual Cross Quality Control in Medical Record Coding
Objective To explore the feasibility of manual cross quality control medical record coding mode in medical record coding in a tertiary hospital.Methods The inpatient medical record data in the medical record management software of a tertiary specialized hospital from February to December 2021(a total of 10 783 copies)and February to December 2022(a total of 38 133 copies)were extracted.From February to December 2021,only the final quality control method was used.From February to December 2022,the final quality control and the manual cross quality control were carried out.The correct rate of main diagnosis selection,the correct rate of main diagnosis coding,the correct rate of main operation selection and the correct rate of main operation coding were compared between the two periods.Results The correct rate of main diagnostic selection,the correct rate of main diagnostic coding,the correct rate of main surgical selection and the correct rate of main surgical coding of medical record data after final quality control from February to December 2022 were slightly lower than those from February to December 2021,among which the correct rate of main surgical selection and the correct rate of main surgical coding were compared,and the differences were statistically significant(P＜0.05).From February to December 2022,the correct rate of main diagnosis selection,the correct rate of main diagnosis coding,the correct rate of main operation selection and the correct rate of main operation coding of medical record data after final quality control were lower than those of manual cross quality control,and the differences were statistically significant(P＜0.05).After two rounds of quality control from February to December 2022,except that the correct rate of main surgical coding of medical record data was slightly lower than that from February to December 2021,the other three were higher than those from February to December 2021,but the difference was not statistically significant(P＞0.05).Conclusion Manual cross quality control can improve the coding accuracy of medical record data.But manual cross quality control does not show great advantages,it may be related to the high quality of the original coding in the hospital,less room for improvement,and personnel changes.The implementation of the manual cross quality control medical record coding mode enables the tertiary hospital to avoid a significant decline in coding quality due to personnel changes.This model is worthy of hospital exploration and practice.
Medical record codingManual cross quality controlFinal quality controlManagement quality
国家科技期刊平台
NSTL
万方数据
