The Influence Factors of Main Diagnosis Coding Quality on the Front Page of Medical Records From a Class A Tertiary Comprehensive Hospital
Objective To analyze the influence of different coders'characteristics on the quality of main diagnostic codes on the front page of medical records in a class A tertiary comprehensive hospital in Xiamen,and put forward some measures for improving the quality of main codes on the front page of inpatient medical records.Methods A stratified sampling method was used to select 3 316 discharged medical records of 9 coders from a class A tertiary comprehensive hospital in Xiamen from January to December 2023 for cross-checking.The error rate of the main diagnostic coding on the front page of the medical records was statistically analyzed.The impact of different work seniority,specialty,educational level,professional title,and coding certificate of coders on the error rate of main diagnostic codes on the front page of medical records was explored.Results In this study,35 medical records were excluded due to errors in information retrieval by the system,resulting in a total of 3 281 medical records included in the statistics.A total of 318 main diagnosis coding errors were identified on the homepage,resulting in an error rate of 9.69%.(1)The error rate of the main diagnostic coding on the first page of the medical records among coders with over 10 years of work seniority was 8.14%,which was lower than that of coders with less than 5 years of work seniority(12.13%),and the difference was statistically significant(P<0.05).(2)Among coders with different professional backgrounds,the main diagnostic coding error rate on the front page of the medical records of health information management coders was the lowest at 8.33%,lower than that of clinical medicine coders and non-medical coders(13.45%,11.43%).The main diagnostic coding error rate on the front page of the medical records of nursing coders was lower than that of non-medical coders(8.54%vs.11.43%).The differences were statistically significant(P<0.05).(3)The main diagnostic coding error rate on the front page of the medical records for junior professional and technical title coders was 11.49%,which was higher than the 8.46%for intermediate titles and 7.64%for senior titles,and the differences were statistically significant(P<0.05).(4)The main diagnostic coding error rate on the front page of medical records for coders with coding certificates is 8.29%,which is lower than the 13.82%for coders without coding certificates,and the difference is statistically significant(P<0.05).Conclusion Coders with longer work experience,higher professional titles,and coding training qualification certificates have lower error rates in primary diagnosis coding on the first page of medical records,indicating good coding quality.This suggests that the work experience,professional background,professional titles and possession of coding certification can significantly influence the quality of coding on the front page of medical records.Optimizing the allocation of medical coders,strengthening the construction of coding teams,and continuously improving the capabilities of coding personnel are crucial for improving the quality of main diagnosis coding on the front page of medical records.
class A tertiary comprehensive hospitalfront page of medical recordsmain diagnosis codingcoding error ratecoders'basic characteristicscoding quality improvement
万方数据
维普
