Analysis of Filling Out the Front Page of the Inpatient Medical Record for Intestinal Bleeding After the Treatment of Colorectal Polyps
Objectives This study aims to analyze the filling status in the department of Gastroenterology of postoperative intestinal bleeding caused by colorectal polyps treatment on the front page of medical records and improve its accuracy.Methods 28 medical records with the code T81.0 and 14 medical records with the code K92.209 including main diagnosis or other diagnosis in the Department of Gastroenterology of a tertiary general hospital from January 1,2017 to December 31,2022 screened out from medical records statistics management system of medical institutions in Guangdong province.The coder and the quality control physician checked the medical records one by one and jointly determined whether the condition met the requirement of intestinal bleeding after treatment of colorectal polyps.Among them,23 medical records coded as T81.0 met the requirements,and 8 medical records coded as K92.209 met the requirements,totaling 31 records.Descriptive analysis was used,and count data were expressed as frequency,percentage,and accuracy.Results Among the 31 medical records,9 were filled in correctly by the physician and coded correctly by the coder,accounting for 29.0％.There were 14 cases where the physician filled in the wrong information,but the coder coded it correctly,accounting for 45.2％,and there were 8 cases where the physician filled in the wrong information,but the coder made the same mistake,accounting for 25.8％.There were 20 correct answers from the physicians for the admission conditions,accounting for 64.5％,and 11 incorrect answers,accounting for 35.5％.The check found that 8 cases(25.8％)should have been classified as 1(yes);2 cases(6.5％)should have been classified as 2(clinically undetermined);21 cases(67.7％)have been classified as 4(none).Conclusions There are prominent problems in filling out the first page of the gastroenterology inpatient medical record regarding intestinal bleeding after treatment of colorectal polyps.The main factor is the doctor's wrong filling,followed by the coder's mistakes.Therefore,the hospital's competent departments and clinical departments should attach great importance to it,strengthen the learning and training of physicians and coders on intestinal bleeding after treatment of colorectal polyps,and improve the accuracy of filling out the front page of the inpatient medical record.
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