某地区病案首页诊断编码质量的故障树分析

目的通过建立病案首页诊断编码质量的故障树分析模型,从而为病案首页诊断编码质量不高的原因分析提供理论参考与指导。方法向某地区29家县级以上医疗机构病案科发放问卷调查表并深入访谈,结合中国期刊全文数据库相关文章,利用收集和整理的数据资料与理论知识应用故障树分析法(FTA)进行病案首页诊断编码质量的风险分析。结果通过提取问卷调查表数据,影响疾病编码的主要因素为临床诊断理解程度、ICD运用熟悉度、医师沟通效果、薪酬满意度等,对应不满意率分别为38.09%、33.33%、32.38%、27.62%;从事编码工作女性与男性工作者占比分别为63.81%、36.19%;从事编码工作者的专业来源广泛,其中护理学与统计学较多,分别占24.76%与29.52%;而通过期刊论文数据库搜索结果总结出医师有无进修或规范化培训经历、医院对病案首页重视程度、临床医师对病案首页填写责任心、病案首页信息填报质控以及对医师进行病案首页培训的力度等方面为影响病案首页诊断编码质量主要因素。将各因素利用故障树模型分析,能够将病案首页诊断编码质量不佳的原因归类于编码员自身问题、临床医师问题以及制度流程问题3个维度。结论针对故障树模型分析出的原因,应从提高编码员专业素质、规范临床医师诊断书写、优化医院规章制度3个方面降低病案首页诊断编码错误的风险,提高病案首页编码质量。

Fault Tree Analysis on Diagnostic Coding Quality of the Front Pages of Medical Records in a Region

Objectives To establish a fault tree analysis model for the diagnosis coding quality of the front pages of medical records,so as to provide theoretical reference and guidance for the analysis of the reasons for the low diagnosis coding quality of the front pages of medical records.Methods Questionnaires were distributed to the medical record departments of 29 medical institutions above the county level in a certain region and in-depth interviews were conducted.Based on the relevant articles in the CNKI,the collected and collated data and theoretical knowledge were used to analyze the risk of the quality of the first page diagnostic codes by fault tree analysis(FTA).Results By extracting questionnaire data,the main factors affecting disease coding were clinical diagnosis understanding,ICD application familiarity,physician communication effect,and salary satisfaction.The corresponding dissatisfaction rates were 38.09%,33.33%,32.38%,and 27.62%,respectively.The percentages of female and male workers engaged in coding work were 63.81% and 36.19% respectively.University professionals engaged in coding had a wide range of sources,including nursing and statistics,accounting for 24.76% and 29.52% respectively.According to the search results of CNKI,it was concluded that the main factors affecting the quality of diagnosis codes on the front pages of medical records were whether doctors had further education or standardized training experience,the importance attached by hospitals to the first page of medical records,the responsibility of clinicians to fill in the front pages of medical records,the quality control of filling in the front pages of medical records,and the strength of training doctors on the front pages of medical records.Using fault tree model to analyze the factors,the reasons for the poor quality of diagnosis codes on the front pages of medical records could be classified into three dimensions:the problems of the coders themselves,the problems of clinicians and the problems of system processes.Conclusions According to the reasons analyzed by the fault tree model,the risks of coding errors on the front pages of diagnosis should be reduced from three aspects:improving the professional quality of coders,standardizing the writing of diagnosis by clinicians,and optimizing hospital rules and regulations,so as to improve the quality level of coding on the front pages.