Analysis of Coding Quality Based on the Front Pages of 2378 Inpatient Medical Records from a Hospital
Objectives By analyzing the coding quality of the front page of inpatient medical records in a hospital,we could understand the coding status quo and provide reference for improving the coding quality of diseases and surgical operations.Methods The discharged medical records of a hospital from May 1st,2021 to December 31st,2021 were randomly selected by a coded quality control officer.The code quality control officer conducted quality control on the front page of inpatient medical records in 22 clinical departments of the hospital,randomly selected about 300 front pages of inpatient medical records every month,and extracted and controlled a total of 2378 front pages of inpatient medical records.According to the National Health Commission issued"Inpatient Medical records front page data filling quality standards(interim)""Inpatient medical records front page data quality management and control indicators(2016 version)"to determine whether the diagnosis and surgery and operation selection was correct.According to the coding principles in the International Classification of Diseases(ICD-10)Volumes Ⅰ and Ⅲ,and the Classification of Surgical Operations(ICD-9-CM-3)(2011 edition),the coding situation of coders in a certain hospital was analyzed according to the disease coding evaluation table generated by the quality control results.Results Of the 2378 inpatient medical records of quality control,1 892 were without defects and 486 were with defects,with a defect rate of 20.44％.Among the 486 medical records with defects,there were 100 defects in main diagnostic codes,355 defects in other diagnostic codes,40 defects in main surgical codes and 65 defects in other surgical codes,accounting for 20.58％,73.05％,8.23％and 13.37％of the total defects respectively.486 medical records with defects were carefully reviewed,and the specific types of defects of coders were summarized.Among them,multi-coding was the most defective in disease diagnosis coding,accounting for 28.13％,and missing coding was the most defective in surgery and operation,accounting for 35.24％.Conclusions In discharge diagnosis,surgery and operation coding,the defects of coding were many problems,such as multi-coding,ignoring etiology in coding,unrefined coding and missing coding.
Front pages of medical recordDiseases codingDefectCoder
NETL
NSTL
万方数据
