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.
李小丹 ;许名东. 基于2414份住院病案首页数据缺陷分析及干预前后效果评价[J]. 中国当代医药, 2018, 25(14): 148-151.
LI Xiao-dan; XU Ming-dong. Defect analysis based on homepage data of 2414 hospitalization medical records and pre-and post-interventional effect evaluation. 中国当代医药, 2018, 25(14): 148-151.