【摘要】 目的通过住院病案首页编码抽样质控数据汇总，分析编码错误原因提出改进措施，逐步提升编码质量。方法 2021年1月1日-2021年11月30日出院病案中6位编码质控员对科室20位编码员进行抽样质控，每人每月50份病案，共计10 450份住院病案首页数据，通过Excel 2017汇总分类编码错误，分析错误原因。结果 编码员年资10年以上的平均编码正确率为98.58%,5年以下的为96.29%。ICD编码质控缺陷率最高的为主要诊断编码(42.00%)，其他依次为其他诊断编码(32.20%)、主要手术操作编码(16.40%)、其他手术操作编码(8.10%)。编码缺陷的原因主要为未认真分析病案(47.15%)、未掌握编码原则(24.86%)、新规政策学习不到位(10.86%)、与临床医师沟通不足(10.68%)、专业知识不足(6.45%)。编码缺陷率最高的科室是肿瘤放疗科为18.46%，其他较高的科室依次为消化内科16.00%，肿瘤内科为13.91%，肿瘤精准医学科13.33%，急诊内科11.15%，肿瘤综合治疗科10.91%。结论 通过编码质控寻找缺陷问题原因，有针对性的采取加强编码人才队伍建设和强化编码人员知识技能培训来提升编码员职业素养，加大与临床科室互动提高病历书写质量，持续优化编码信息系统杜绝编码低级错误等具体改进措施，有效提升编码质量。更多还原

【Abstract】 Objectives This study aims to analyze the causes of coding errors by summarizing the ICD coding sampling quality control data on the front page of inpatient medical records and put forward measures to improve the coding accuracy, so as to continuously improve the coding quality.Methods Among the discharged medical records from January 1, 2021 to November 30, 2021, Six coding quality controllers sampled quality control data on the front pages of inpatient medical records of 20 coders in the department, each with 50 medical records per month, with a total of 10 450 medical records. Excel2017 was used to summarize the classification and coding error problems, and the wrong medical records were reviewed and analyzed.Results The average coding accuracy of coders with more than 10 years of experience was 98.58%, and that of coders with less than 5 years was 96.29%. The highest ICD coding QC defect was the main diagnostic codes(42.00%), followed by other diagnostic codes(32.20%), main surgical codes(16.40%), and other surgical codes(8.10%). The main reasons for coding defects were failure to carefully analyze medical records(47.15%), failure to master coding principles(24.86%), inadequate study of new rules and policies(10.86%), insufficient communication with clinicians(10.68%), and lack of professional knowledge(6.45%). The department with the highest coding defect rate was the Department of Tumor Radiotherapy(18.46%). Other departments with the highest coding defect rate were the Department of Gastroenterology(16.00%), the Department of Tumor Medicine(13.91%), the Department of Cancer Precision Medicine(13.33%), the Department of Emergency Medicine(11.15%), and the Department of Comprehensive Tumor Therapy(10.91%). Conclusions Finding the cause of defects through ICD coding quality control, strengthening the construction of coding talent team and strengthening the knowledge and skills training of coders to improve the professional quality of coders, improving the writing quality of inpatient medical records by increasing the interaction with clinical departments, and continuously optimizing the coding information system to eliminate specific improvement measures such as low-level coding errors can effectively improve encoding quality.更多还原