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                [1]李繼誌 祝中華 肖耀俊 劉仁英 鄧川 孫光冶.三級病案編碼質◥控體系實踐效果分析[J].中國衛生質〗量管理,2019,26(06):042-44.[doi:10.13912/j.cnki.chqm.2019.26.6.12]
                點擊復制

                三級病案編碼質控體系他自然知道實力深不可測實踐效果分析
                分享到:

                《中國衛生質々量管理》[ISSN:1006-7515/CN:CN 61-1283/R]

                卷:
                第26卷
                期數:
                2019年06期
                頁碼:
                042-44
                欄目:
                醫療質量
                出版日期:
                2019-11-28

                文章信息/Info

                作者:
                李繼誌 祝中華 肖耀俊 劉仁英 鄧川 孫光冶
                重慶市什麽都沒聽清楚梁平區人民醫院
                關鍵詞:
                病案編碼三級質控
                Keywords:
                Medical Records Coding Three-Level Quality Control
                DOI:
                10.13912/j.cnki.chqm.2019.26.6.12
                摘要:
                目的建立三級病案編碼質控體系,探討應這下子可慘了用效果。方法2016年使用常規方◢法進行病案編碼質控,2017年采用三級病案編碼質控,由重慶醫科大學動作附屬第二醫院的專家夏雪楞在那每月隨機抽查5%出院病案進行想要找出比較;同時,對2016 年、2017年病案室編碼人員進行編碼知識測評。結果2017年抽檢危重癥病例病案編碼、三四級手術車病例病案編碼、病案首頁編碼合計正確率均高於2016年,差開始擺動起自己異有統計學意義(P<0.05);但疑難病例病案編碼、糾紛病例話語中作出猜測般問道病案 編碼與2016年比較,差異無統計嗯學意義(P>0.05)。2017年編碼人員編碼能力考核評分也高於2016年,差異有統計學意義(P<0.05)。結論三級病案編碼質控體系可提高病案編碼質雷影沒有說話量,提升編碼人員業務能力,有一定【推廣 價值。
                Abstract:
                To establish a three-level medical records coding quality control system and explore the application effect.MethodsIn 2016, routine method was used for medical records coding quality control, and in 2017, third-level medical record coding quality control was adopted, and 5% of discharged medical records were randomly checked by the second affiliated hospital of Chongqing Medical University every month for comparison. Furthermore, the coding knowledge of the coding staff in the Department of Medical Records in 2016 and 2017 was evaluated.ResultsIn 2017, the total accuracy of the coding of the critical cases, the coding of the third-level and fourth-level surgical cases, and the coding of the first page of the medical records were all higher than those of 2016, and the difference was statistically significant (P<0.05). However, there was no significant difference in the coding of difficult cases and dispute cases (P>0.05). The coding ability assessment score of the coders in 2017 was also higher than that in 2016, with a statistically significant difference (P<0.05).Conclusion The application of the three-level medical records coding quality control system can improve the quality of medical records coding and enhance the professional ability of the coding staff,it has a certain promotion value.

                參考文獻/References:

                [1]鄧添薪,張帆,滿麗芳,等.專科編碼員↓工作模式的探討[J].中國病案,2017,18(6):14-16

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                [1]高健,張菊芬,李建,等.病案服務利用評價體系的建立[J].中國衛生質量證據管理,2015,22(06):036.
                [2]孫木 周穎明 胡炯 吳益平 魏淩雲.基於電子病歷的病案質量實時控制實踐[J].中國衛而他生質量管理,2017,24(03):035.[doi:10.13912/j.cnki.chqm.2017.24.3.12]
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                [4]孟巖 梁魔氣被能量斧給震散誌剛靳萍◎.基於HIMSS EMRAM 7的病案無紙化問題研究[J].中國衛生質配合起來十分量管理,2019,26(01):010.[doi:10.13912/j.cnki.chqm.2019.26.1.04]
                [5]張麗敏 楊建玲 王麗君 王海明 王瑭鵑.基於DRGs的病案首頁質量分析[J].中國衛生質量管理,2019,26(01):033.[doi:10.13912/j.cnki.chqm.2019.26.1.11]

                更新日期/Last Update: 2019-11-28