李小丹 许名东

[摘要]目的 通過对本院住院病案首页数据存在缺陷的原因进行分析，并采取一定的干预措施，观察干预前后病案首页数据、编码质量的改进效果。方法 回顾本院2015年9月～2016年3月住院病案首页编码情况，随机选取1207份病案作为干预前组，查找病案首页存在的编码质量缺陷，对缺陷原因进行归纳分析，通过加强本院临床医师和编码员的培训与学习后，随机从2017年1～6月选取1207份住院病案作为干预后组，对培训前后各1207份病案首页的数据、编码质量进行比较。结果 干预前组的病案缺陷率为76.5%，干预后组的病案缺陷率为15.9%，干预后组病案首页数据与编码质量较干预前组有显著提高（P<0.01）。编码缺陷的项目主要包括基本信息漏填错填、医师主要诊断选择错误、手术及操作信息漏填或误填、病案首页其他信息错误等7项。结论 通过归纳分析，查找病案首页填写存在的编码缺陷，制订出增强临床医师责任心的政策，加强病案首页填报培训学习及编码员与医师沟通，加强病案编码过程的管理，是提高病案首页编码质量的关键，也是建立临床医师与病案编码员沟通的桥梁。

[关键词]病案首页；数据缺陷；干预；效果评价

[中图分类号] R197.323 [文献标识码] A [文章编号] 1674-4721（2018）5（b）-0148-04

Defect analysis based on homepage data of 2414 hospitalization medical records and pre- and post-interventional effect evaluation

LI Xiao-dan XU Ming-dong

Department of Medical Records，People′s Hospital of Sanshui District of Foshan City in Guangdong Province，Foshan 528100，China

[Abstract]Objective To analyze the reasons for the defects of data in the homepage of hospitalization medical records and take some intervention measures so as to observe the improvement effect of the data and the coding quality in the homepage of the medical records before and after the intervention.Methods The coding for the home page of hospitalization medical records from September 2015 to March 2016 in our hospital was retrospectively reviewed.Altogether 1207 medical records were randomly selected as the pre-intervention group to find out the defects of the coding quality in the homepage of the medical records.The reasons for the defects were summarized and analyzed.After strengthened training of the clinicians and coders in our hospital，1207 hospitalization medical records from January to June in 2017 were randomly selected as the post-intervention group.The data and coding quality of 1207 hospitalization medical records were compared before and after training.Results The medical record defect rate of the pre-intervention group and post-intervention group was 76.5% and 15.9%，respectively.The data and coding quality of the homepage of the medical records in the post-intervention group were significantly higher than those in the pre-intervention group （P<0.01）.The main items of the coding defect included the missing or wrong basic information，error information in doctor′s main diagnosis and selection，missing or wrong surgical and operation information，and other information errors in the homepage of the medical records.Conclusion The coding defects in the front page of medical records is found through inductive analysis.And the policy of strengthening the responsibility of the clinicians is formulated to strengthen the training and study of how to fill in the homepage of the medical records，communication between the coders and the doctors，and management of the coding process of the medical records.It is the key to improve the coding quality of the homepage of the medical records，and also a bridge to establish good communication between the clinician and the medical record coders.

[Key words]Homepage of the medical records；Data defect；Intervention；Effect evaluation

病案首页概括整份住院病历中最重要的信息，是整份住院病历信息的综合反映，是医院进行医疗、教学、科研的重要原始数据[1]。病案首页数据既是卫生主管部门或质控部门进行医院管理、医疗质量管理的集中体现，也是医院绩效评价最直接的数据来源和评价的依据，是一种具有法律效力的文书，可作为处理医疗矛盾和事故的法律依据及社保部门疾病诊断相关分组（DRGs）单病种医疗付费的清算依据[2-3]。通过对本院2015年9月～2016年3月的1207份住院病案首页的数据和编码质量进行分析，查找病案首页编码质量缺陷的主要原因，并针对病案首页数据缺陷存在的问题采取相应的干预措施，加强本院临床医师和编码员的培训与学习。……