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目的通过回顾性分析临床医师在病案首页中呼吸机使用时间和相关操作名称的填报情况,探讨病案首页书写质量对手术操作编码准确性的影响。方法检索某院2014年1月-6月及2015年1月-6月住院病案首页中所有涉及呼吸机使用时间及相应操作名称的住院病案共1505例,逐一查阅核对住院病案内容,分析临床医师呼吸机使用时间和操作名称的填写情况,以及编码员对于使用呼吸机的ICD操作编码,并对两个时间段的填报质量进行对比分析,统计方法为描述性统计。结果两年中相同时间段住院病案首页中呼吸机使用数据进行比较,临床医师漏填率下降30.52%;编码员呼吸机操作编码漏编及错编率降低28.86%。医师漏填的病案与编码员漏编及错编的病案主要集中在心外科及胸外科,两科2014年漏填率52.45%、漏编错编率47.42%;2015年漏填率44.83%、漏编错编率83.33%。结论通过加强对病案首页呼吸机填写情况的质控及编码质量的改进,提高了病案首页数据的完整性和准确性,为呼吸机使用数据填报质量打下坚实基础。
OBJECTIVE: To investigate the effect of writing quality of medical records on the accuracy of surgical procedures by retrospectively analyzing the clinicians’ reporting of the time of using the ventilator and the names of related operations on the first page of medical records. Methods A total of 1,505 inpatient cases involving the duration of ventilator use and the corresponding operation name in the first page of hospitalized cases in January-June 2014 and January-June 2015 in a hospital were searched. The inpatients were examined one by one to check the contents of hospitalized cases, and the clinicians Ventilator use time and name of the operation of the filling, as well as the coder for the use of ventilator ICD encoding operation, and the quality of the two time periods to compare the quality of filling, statistical methods for the descriptive statistics. Results In the two years, the leakage rate of clinicians dropped by 30.52% compared with that of the first page of hospitalized patients in the same period of two years. Medical records of missed cases by doctors and coders were mainly classified as cardiothoracic surgery and thoracic surgery. The leakage rate of both subjects in 2014 was 52.45%, accounting for 47.42% of the total. In 2015, the leakage rate was 44.83% The wrong editing rate of 83.33%. Conclusion By improving the quality control and coding quality of the first page of the medical records, the integrity and accuracy of the first page of the medical records are improved, laying a solid foundation for the quality of the data to be used in the ventilator.