论文部分内容阅读
目的在军队医院等级评审过程中,首次采用双盲同行评议形式,探索一种科学评价病案首页疾病编码质量的方法,以期能在评审中客观横向比较参评医院首页质量。方法回顾性随机抽查6所中心医院2013年终末病案各50份,采用双盲同行评议法审核医院病案首页编码质量,得出编码正确率。结果各医院编码正确率在32%~80%之间,均低于90%的三甲标准。主要诊断选择和手术编码缺陷率39.00%。结论部分医院首页质量亟待提高。双盲法同行评议能够真实反映各医院疾病编码水平,值得在各级病案质控中心活动、等级医院评审中借鉴,有利于促进病案学科发展,提升医院信息化建设水平。
Objective To evaluate the quality of disease coding on the first page of the military hospital by using double-blind peer review in the process of military hospital grade review, in order to objectively and horizontally compare the quality of homepage of the participating hospitals in the review. Methods Retrospective random sampling of 6 central hospitals in the end of 2013 50 cases of each case, using double-blind peer review method to review the first page coding quality of hospital medical records, the coding accuracy. Results The correct coding rates of all hospitals were between 32% and 80%, all lower than 90% of the top three standards. The main diagnostic options and surgical coding defect rate of 39.00%. Conclusion Some hospitals need to improve the quality of the home page. Double-blind peer-review can truly reflect the level of disease coding in all hospitals, which is worthy of reference at all levels of the quality-of-control center and at the level of hospital accreditation. It is conducive to promoting the development of medical records and enhancing the level of hospital informatization.