Common Problems and Solutions Strategy to Disease and Surgical Coding on the Medical Record Homepage
Objective To analyze common problems with disease and surgical coding on the medical record homepage,and propose targeted solutions. Methods A total of 1000 medical records included in the medical records statistical management system of Zhangzhou Affiliated Hospital of Fujian Medical University from January to June 2022 were selected as the research objects. A total of 500 medical records included from January to March 2022 were before intervention,and the 500 medical records included from April to June 2022 were after intervention. The incidence of disease and surgical coding errors before and after intervention and the causes of disease and surgical coding problems before intervention were analyzed. Results The proportion of disease and surgical coding errors on the medical record homepage after intervention was 13.20％,lower than 21.00％ before intervention,and the difference was statistically significant (P<0.05). The main reasons for coding errors were unclear coding by coders,misuse of residual categories by coders,non classification of coding,and non-standard writing by physicians. Conclusion Disease and surgical coding on the medical record homepage are prone to problems. In response to common coding problems,optimization measures such as quality control,professional training,and hospital information construction should be selected to improve the quality of the disease and surgical coding on the medical record homepage.
medical record homepagediseasesurgicalcodingfrequently asked questionssolution strategy
万方数据
维普
