非计划再次手术患者住院病案首页质量缺陷分析

目的 分析非计划再次手术患者住院病案首页疾病诊断和手术操作ICD编码错误情况,提高并发症诊断、再次手术编码准确性、探索改进措施.方法 通过医院信息系统收集某三甲医院2019年全年在同一次住院期间的不同时间段进行两次或多次手术的患者病案,最后共计获得非计划再次手术的病案126份.对非计划再次手术住院病案首页诊断填报进行分...

Analysis of Quality Defects on the First Page of Medical Records of Unplanned Reoperation

Objective To analyze the error of disease di-agnosis and surgical operation ICD coding on the first page of unplanned reoperation medical records,improve the diagnosis of complications,reoperation coding accuracy,and explore improvement measures.Methods The hospital information system(HIS)was used to collect medical records of patients who had undergone two or more operations at different time periods during the same hospital stay in a tertiary hospital throughout 2019.Finally,a total of 126 unplanned reoperations were obtained.Results Among the 126 unplanned reoperation cases,74 cases were found with defective first page quality,with an error rate of 58.73%.In 74 cases,error codes are at most for postoperative complications diagnosis codes.A total of27 cases have an error rate of 36.48%.Among them,"postoperative infection"and"postoperative pleural effusion/pneumothorax"have the highest coding error rate,accounting for the wrong medical records respectively.40.73%and 29.63%of the total.The second is unplanned reoperation code errors,a total of 19 cases,of which"postoperative bleeding hemostasis"code error rate is the highest,accounting for 36.85%of the wrong medical records.Conclusion Inadequate understanding of the principles of disease classification by coders and insufficient standardization of writing by clinicians are the main reasons for coding errors.It is necessary to strengthen the training of clinical doctors in writing standard medical records and the professional knowledge learning of coders.