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目的通过对某三甲医院死亡病案首页诊疗信息的填报质量分析,明确临床医师与编码员在病案首页填报中存在的问题及改进方法。方法选取2015年10月1日-2016年9月30日死亡病案493份,病案质控医师以相同标准对临床医师填报及编码员ICD编码后的病案首页诊疗信息进行对照检查,检查结果经病案科、医院质量控制与评估办公室、临床医师共同确认后进行汇总分析。结果病案首页诊疗信息填报完全正确率:临床医师为10.14%,编码员为30.02%;临床医师主要诊断填写错误与不准确合计占到38.24%,其他诊断漏诊占44.49%,其他手术/操作漏填占到43.01%。结论临床医师及编码员在病案首页信息的正确上报中起着至关重要的作用。加强临床医学知识和主要诊断选择原则的相关培训,以及临床医师和编码员密切沟通是提高病案首页填报质量的最佳途径。
Objective To analyze the quality of filling out the first page of the death records of a top three hospital and clarify the existing problems and improvement methods of the clinicians and coders in the first page of the record. Methods A total of 493 cases of death were selected from October 1, 2015 to September 30, 2016. The case-control physicians conducted the same examination on the first home-page information of clinicians filing by the clinician and the coder ICD, Section, the hospital quality control and evaluation office, clinicians confirmed after the summary analysis. The results of the first page of medical records of medical information reporting complete correct rate: the clinician was 10.14%, the coder was 30.02%; clinicians fill in the main diagnostic errors and inaccuracies accounted for 38.24%, 44.49% other misdiagnosis, other surgery / operation Accounting for 43.01%. Conclusion Clinicians and coders play an important role in the correct reporting of the first page of medical record. Strengthening training in clinical medicine and principles of primary diagnosis and selection, as well as close communication between clinicians and coders, is the best way to improve the quality of the first page of medical records.