Analysis on the Accuracy of Main Diagnosis Selection in 406 Orthopedic Medical Records
Objectives To explore the main diagnosis problems in the front page of orthopedic medical records,and put forward targeted suggestions.Methods 406 medical records of discharged orthopedic patients from March 1st,2022 to May 31st,2022 were selected as the research objects.Two medical records coders and two quality control physicians initially screened out medical records with major diagnostic defects according to the basic principles of the main diagnosis selection in the 2016"Quality Specification for Filling in the Front Page Data of Inpatient Medical Records(Interim)"and ICD-10 coding rules.After discussion and confirmation with clinicians,the statistics were summarized into Excel tables,and some cases were analyzed.Results Among the 406 front pages of orthopedic medical records,84(20.7%)cases were found to have major diagnostic errors,including 44 cases with major diagnostic selection errors.There were 40 errors in the main diagnosis coding.The main reasons for the selection of the main diagnosis were general diagnosis,not choosing the etiology as the main diagnosis,the main diagnosis and pathological diagnosis did not meet,postoperative complications as the main diagnosis and invalid main diagnosis.The main causes of diagnostic coding errors were uncombined coding,general coding,and inconformity between diagnostic coding and pathological diagnosis.Conclusions The accuracy of main diagnosis selection in orthopedics was low.It was suggested to improve the accuracy of main diagnosis selection and coding in orthopedics by strengthening the training of clinicians'main diagnosis and related ICD knowledge,improving the professional and technical level of coders,and improving the effective communication mechanism between coders and clinicians.
NETL
NSTL
万方数据
