Research on the Continuous Improvement of the Quality of Disease Major Diagnosis Coding by Clinicians in A Large Teaching Hospital_West China Medical Journal

Authors：

 LiaoGuirong , LuoJian ,  MoChunmei

Medical Record Section, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;

Corresponding?author：

MoChunmei, Email: 858097951@qq.com

Keywords：

Coding by doctors; Major coding; International classification of diseases

DOI：

10.7507/1002-0179.201600261

Video：

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Objective To encourage clinicians to code the major diagnosis of diseases, in order to improve the correct rate of disease major diagnosis coding. Methods We analyzed the data of major diagnostic codes by clinicians from January 2012 to June 2013. The group leader of the clinical treatment was designated to be responsible for the disease coding. Disease coders introduced knowledge of international classification of diseases to the clinical department according to the different characteristics of disease in each department and communicated with clinicians on the problems of disease coding. Then, we tried to find out whether this method could improve the correct rate of major diagnosis coding of diseases. Results The rate of disease major coding by clinicians of the whole hospital and pilot departments increased from 94.081% to 98.301%. The correct rate of disease major coding decreased from 75.824% to 67.483% and then reached 81.893%. The correct rate of disease major coding of the Department of Hematology was 83.824% in August 2012 and then decreased with the lowest rate of 68.025%; and the correct rate of disease major coding of the Department of Orthopedics increased rapidly and reached 90% in September 2012. Conclusions Through the leader of the clinical treatment being responsible for the disease coding and encouraging clinicians to code the main diagnosis of diseases, the accurate of disease major diagnosis coding has improved. Strengthening the communication between clinical and Medical Record Departments can help our hospital improve the quality of disease major diagnosis coding continuously.

Citation： LiaoGuirong, LuoJian, MoChunmei. Research on the Continuous Improvement of the Quality of Disease Major Diagnosis Coding by Clinicians in A Large Teaching Hospital. West China Medical Journal, 2016, 31(5): 963-967. doi: 10.7507/1002-0179.201600261 Copy

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11.	王文達, 達漢玲, 秦安京. 病案摘錄是DRGs研究課題的重要環節[J]. 中國病案, 2007, 8(7): 8-10.
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14.	宋俊, 陳宇邦, 鄭映蘋. 建立有效學習機制提升病案編碼水平[J]. 現代醫院, 2013, 13(5): 127-128.
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1. 簡偉研, 胡牧, 崔濤, 等. 運用疾病診斷相關組進行臨床服務績效評價初探[J]. 中華醫院管理雜志, 2006, 22(11): 736-739.
2. 劉春萍, 徐長妍, 馬洪喜. 臨床路徑挑戰病案管理模式[J]. 中國病案, 2011, 12(2): 19-20.
3. 耿連華. 疾病編碼的質量分析與對策[J]. 中國病案, 2012, 13(8): 31-32.
4. 中華人民共和國衛生部. 衛生部辦公廳關于印發《三級綜合醫院評審標準實施細則（2011年版）》的通知[EB/OL]. (2011-12- 23)[2014-01-01]. http://www.nhfpc.gov.cn/yzygj/s3585u/201112/06f754a213d8413787904e9e6439d88b.shtml.
5. 黃鋒, 陳劍銘. 醫院病案管理工作現狀及發展趨勢探討[J]. 中華醫院管理雜志, 2013, 29(3): 192-194.
6. 中華人民共和國衛生部. 衛生部關于修訂住院病案首頁的通知[EB/OL]. (2011-11-02)[2014-01-01]. http://www.nhfpc.gov.cn/mohyzs/s3585/201111/53492.shtml.
7. 范俊葉, 彭新蘭, 韓琪, 等. 對醫師進行ICD相關知識培訓的探討[J]. 中國病案, 2012, 13(1): 59-61.
8. 喬英, 袁君君, 李恒愛. 臨床醫生認真寫好病歷是提高ICD-10編碼準確性的關鍵[J]. 中國實用醫藥, 2011, 6(14): 249-250.
9. 黃小龍. 疾病編碼對醫療質量的影響[J]. 軟化醫學電子雜志, 2015, 2(3): 164-165.
10. 范俊葉, 孫來廣, 范俊生, 等. 基于PDCA循環下編目工作的持續改進[J]. 中國病案, 2014, 15(2): 10-11.
11. 王文達, 達漢玲, 秦安京. 病案摘錄是DRGs研究課題的重要環節[J]. 中國病案, 2007, 8(7): 8-10.
12. 劉葉琴. 疾病分類準確性是診斷相關分組的關鍵[J]. 中國藥物與臨床, 2016, 16(2), 288-289.
13. 張惠娟, 陳佩貞. 疾病診斷及其編碼的準確性是實施DGRs支付方式的關鍵[J]. 中醫藥管理雜志, 2013, 21(2): 197-199.
14. 宋俊, 陳宇邦, 鄭映蘋. 建立有效學習機制提升病案編碼水平[J]. 現代醫院, 2013, 13(5): 127-128.
15. 魏威, 陳忻, 陳劍銘, 等. 病案首頁疾病診斷缺陷分析[J]. 中國病案, 2014, 15(7): 14-16.
16. 吳文華, 邱杰. 影響疾病分類數據庫準確性的因素[J]. 中國病案, 2008, 9(6): 34-35.

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Research on the Continuous Improvement of the Quality of Disease Major Diagnosis Coding by Clinicians in A Large Teaching Hospital

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