Quality Analysis on the ICD coding of the Front Page of 1000 Inpatient Medical Records in a Hospital
Objectives To investigate the problems in the ICD coding of the front page of medical records in a tertiary hospital in a certain city,in order to find effective improvement measures to improve the quality of data on the front page of inpatient medical records.Methods A total of 1000 discharged medical records from a tertiary hospital in a city were selected by stratified random sampling method from January 1st,2023 to June 30th,2023.According to the filling requirements of disease diagnosis and surgical operation in the national Disease Classification and Code application guidance manual,the diagnosis and surgical operation of the extracted medical records were re-checked and the tertiary quality control method was adopted.Microsoft Office Excel 2013 tables were used to record the ICD coding errors of each department in detail,and the category distribution of coding errors was counted.Results As a result,from January 1st to June 30th,2023,there were 23147 inpatient medical records on the front page.Out of 7％,1000 inpatient medical records were selected as the subjects for examination.After checking the front pages of 1000 inpatient medical records,215 were incorrectly coded,with a coding error rate of 21.5％.The number of main diagnostic errors was 93(63.70％),while the number of other diagnostic errors was 53(36.30％);There were 51 cases of major surgical/operational errors(73.91％),and 18 cases of other diagnostic errors(26.09％).Conclusions The quality of ICD coding was related to the writing of clinicians and the professional level of coders.We should improve the comprehensive skills of coders and relevant training of clinicians and establish effective communication to continuously improve the accuracy of ICD coding.
Medical record front pageICDCoding qualityAnalysis
NETL
NSTL
万方数据
