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目的探讨病案首页质量控制在提高病案首页主要诊断填报质量中的作用。方法根据国际疾病分类规则和主要诊断选择原则判断主要诊断填写和疾病编码的正确性,分别检索2014年-2015年脑血管病的病案,统计病案首页质量控制前后错误发生例数并计算错误率。结果脑血管病的主要诊断错误率采用病案首页质量控制前是5.33%,采用病案首页质量控制后是1.98%。结论采用病案首页质量控制方法不仅能够提高主要诊断填报的正确率,而且可以逐步规范临床医师对疾病诊断名称的书写,使得疾病编码质量稳步上升。
Objective To explore the role of home page quality control in improving the quality of main medical report forms. Methods According to the rules of international classification of diseases and the principle of main diagnosis and selection, the correctness of main diagnosis and filling and disease coding were determined. The cases of cerebrovascular disease from 2014 to 2015 were retrieved respectively, and the number of errors before and after quality control was counted and the error rate was calculated. Results The main diagnostic error rate of cerebrovascular disease was 5.33% before quality control on the front page of medical record and 1.98% after quality control on the front page of medical record. Conclusion The quality control method of medical record home can not only improve the accuracy of the main diagnostic report, but also gradually standardize the clinicians to write the name of the disease diagnosis, making the quality of disease coding steadily increase.