Investigation on the Correct Rate of Main Diagnosis and Main Operation in 60 Hospitals in a City
Objectives By understanding the current accuracy rate of main diagnosis and surgical procedure codes in the second and third level hospitals in a certain city,we aimed to standardize the selection of main diagnosis and surgical procedure codes,and provide reference for improving the quality of inpatient medical records on the front pages.Methods Using retrospective survey analysis,a team of experts from a medical record quality control center in a certain city conducted on-site inspections of the main diagnoses and surgical procedures on the front pages of 2022 inpatient medical records from 60 second level and above hospitals in the city.Each medical institution selected the top 50 inpatient medical records in order of discharge time on October 15th,totaling 3000.The survey data was statistically analyzed using chi square test.Results The accuracy rate of reporting the main diagnostic code was 93.8％,and the accuracy rate of reporting the main surgical procedure code was 94.8％.Both the accuracy rate of filling in the main diagnostic code and the accuracy rate of coding in tertiary hospitals were higher than those in secondary hospitals,and the difference was statistically significant(P＜0.05).Problem medical records mainly focus on the responsibility of physicians,with the majority of errors being in the selection of incorrect types.The chapter on classification of injuries,poisoning,diseases,and digestive system surgeries has the highest error rate.Conclusions The overall diagnosis and surgical information on the front pages of inpatient medical records in the city was well filled out,but there were differences among hospitals at different levels.Each institution needed to establish a closed-loop management model for quality control of the front page of inpatient medical records,carry out targeted personalized training,strengthen the construction of medical record departments,strengthen the information management of medical records,and promote the accuracy of coding for major diagnoses and surgical operations.
Main diagnostic codeMain surgical proceduresCurrent situation investigationCase management
NETL
NSTL
万方数据
