Analysis of Main Diagnosis Coding Quality on the Front Page of 3 316 Medical Records in Grade A Tertiary General Hospital
Objective To analyze the quality of main diagnosis coding on the first page of inpatient medical records from January to December 2023 in grade A tertiary general hospital in Xiamen City,analyze the causes of coding errors,and put forward effective improvement suggestions to improve the quality of main diagnosis coding on the first page of inpatient medical records in the hospital.Methods Stratified sampling was employed to select 3 316 inpatient medical records from from January to December 2023 in grade A tertiary general hospital in Xiamen City.A total of 9 coders from the department conducted cross-checks on the selected medical records,recording the types of coding errors and analyzing the reasons for these errors.Results There were 353 errors in the major diagnosis codes,resulting in a main diagnosis coding error rate of 10.65％.The errors were categorized as follows:inadequate analysis of medical records(48.44％),lack of understanding of main diagnosis coding principles(27.48％),insufficient clinical knowledge(14.16％),and system retrieval errors(9.92％).Conclusion Pay attention to the construction of medical record coding professional personnel,train the working ability of coders,and promote the improvement and optimization of medical record management system,which is conducive to the continuous optimization of the quality of the main diagnosis coding of medical records.
front page of medical recordsmain diagnosis codingquality analysistypes of coding errorsmedical record management improvementprofessional talent cultivation
NETL
NSTL
万方数据
