【摘要】 目的对该院手术并发症病例进行管理,分析手术并发症病例的首页诊断填写情况及存在的问题,找出整改对策,为医疗质量管理提供准确有效数据。方法选取2016-2018年出现手术并发症的病例658例作为研究对象,对其进行检查分析,查找病历资料,分析首页诊断填写存在的问题及发生原因。结果并发症病例首页填写正确例数515例、错误例数143例,正确率为78.27%,错误率为21.73%。首页诊断存在错误类型例数及占比:医生漏填写诊断121例(84.62%)、医生诊断填写错误2例(1.40%)、编码分类错误20例(13.99%)。该院最常见的手术并发症类型为:术口愈合不良或术口裂开、手术后出血或血肿、术口感染。结论应加强临床医生对首页诊断完整性监控,发挥有效的质量控制管理机制评价首页质量;加强编码员与临床医生沟通,特别是对手术并发症病例存在的问题进行及时纠正,为医疗质量管理提供准确的统计数据。更多还原

【Abstract】 Objective To manage surgical complications in this hospital,analyze the homepage diagnosis and the existing problems of surgical complications,find out corrective measures,and provide accurate and effective data for medical quality management.Methods A total of 658 cases with surgical complications from 2016 to 2018 were selected as the research objects,which were examined and analyzed to find medical records and analyze the problems and causes of the diagnosis on the homepage.Results The first page of complication cases was filled with 515 correct cases and 143 wrong cases,with a correct rate of 78.27%and an error rate of 21.73%.The number and proportion of types of errors on the homepage diagnosis:121 cases were missed by doctors(84.62%),2 cases were incorrectly diagnosed by doctors(1.40%),and 20 cases were incorrectly coded(13.99%).The most common types of surgical complications at the hospital were poor healing or dehiscence of the surgical opening,bleeding or hematoma after surgery,and surgical infection.Conclusion Clinicians should strengthen the monitoring of the integrity of the homepage diagnosis,and play an effective quality control management mechanism to evaluate the quality of the homepage.The communication between the coder and the clinician should be strengthened,and the problems in surgical complications should be corrected in a timely manner to provide accurate statistical data for medical quality management.更多还原