Application of"Double Cycle"Mechanism in Improving The Correct Rate of Main Diagnosis Code in The Front Page of Inpatient Medical Records
Objectives This study aims to explore the application value of"double cycle"mechanism in improving the correct rate of main diagnostic codes on the front page of inpatient medical records,so as to provide a reference for effectively improving the correct rate of main diagnostic codes.Methods The Quality Control Department took the lead in establishing an expert group to randomly select 15%of the front pages of inpatient medical records from the medical record system every month for assessment.The period from June 1,2022 to September 30,2022 was selected as the pre-implementation group,with a total of 2347 cases,including 1241 surgeries and operations.The period from October 1,2022 to May 31,2023 was selected as the post-implementation group of the"double cycle"mechanism,with a total of 6737 cases,including 3625 surgeries and operations.The assessment results were summarized by the Quality Control Department.The main diagnostic coding accuracy rate and related monitoring quality indicators of clinicians and coders were compared before and after the intervention.SPSS22.0 statistical software was used for statistical processing,and P<0.05 indicated that the difference was statistically significant.Results After implementing the'double cycle'mechanism,out of the 6737 cases examined by the hospital,the main diagnosis code was correct in 6410 cases,yielding a correct rate of 95.15%.This rate is significantly higher than the 88.96%observed before implementation,with a statistically significant difference(P<0.05).After the implementation,the defect rate of doctors'main diagnosis filling decreased from 13.98%to 3.34%(P<0.05),and the defect rate of coders'main diagnosis coding inaccuracy decreased from 6.69%to 2.88%(P<0.05).Conclusions The hospital fully harnesses the'double cycle'superposition effect,optimizing the coding workflow.This enables clinicians and coders to quickly familiarize themselves with and master the main diagnosis selection principles,effectively reducing and preventing human errors.Consequently,it gradually improves the accuracy rate of main diagnosis coding on the front page of inpatient medical records,making it both realistic and feasible.However,there are still deficiencies in system construction and process reengineering that need further optimization and refinement in practice.
Double cyclePhysicianMedical records coderMain diagnostic coding accuracy rate