Analysis of Major Diagnosis Coding Errors on the Front Pages of Inpatient Medical Records In a Second Grade A Hospital
Objectives Through analyzing whether the main diagnoses on the front pages of inpatient medical records of a certain hospital in Shanghai in the past three years were correct,to identify the causes of errors,and propose solutions to improve the quality of data on the front pages of inpatient medical records.Methods To randomly select 5208 discharged medical records from January 1st,2019 to December 31st,2021.According to the 2011 edition of the"Instructions for Filling in the Front Pages of Inpatient Medical Records"and the 2016 edition of the"Quality Standards for Filling in the Front Page Data of Inpatient Medical Records(Provisional)",senior coding experts and clinical experts were organized to jointly read and analyze,and the types of errors were divided into three categories:non-standard disease diagnosis names,incorrect selection of main diagnoses,and failure to follow coding rules,which led to main diagnostic coding errors.To describe and statistically analyze the frequency and composition of the main diagnostic coding errors in these discharged medical records.Results A total of 1625 out of 5208 discharged medical records had major diagnostic coding errors,with an error rate of 31.20%.According to the classification of error types,a total of 1365 cases were diagnosed with non-standard names,accounting for 83.99%.Among them,31.63%did not select the cause,23.38%did not refine and clarify the site,22.89%did not combine diagnosis with pathology,and 6.09%did not combine clinical manifestations;209 cases were diagnosed with errors,accounting for 12.86%,and 51 cases did not follow coding rules,accounting for 3.14%.According to department classification,there were 909 errors in surgical departments,accounting for 55.94%,and 716 errors in non-surgical departments,accounting for 44.06%.Conclusions The key to improving the accuracy of the main diagnostic codes was to standardize the name of the disease diagnosis,and clinical physicians should accurately fill in according to the standard requirements;Master the principles of selecting the main diagnosis,and clinical physicians should select the main diagnosis based on the quality standards filled in by the data on the front page of the medical record;Following coding rules,coders should accurately write disease classification codes.
Main diagnosisDisease codingInternational classification of diseasesFront page of hospital medical records
NETL
NSTL
万方数据
