医生与临床编码器的合作有效地提高了编码准确性:中国的一项单中心前性研究
Yicong Xu1, Huanbing Zhu2, Zhijun Xu3
1Medical Records Room, Department of Medical Administration, The Second Affiliated Hospital, Zhejiang University School of Medicine, China.
概括
医生与临床编码器的合作显著提高了临床编码的准确性,使编码器受益. 然而,这种合作并没有改善主页的质量,这与心理因素一起,仍然会影响准确性.
科学领域:
- 医疗信息学 医疗信息学
- 医学编码 医学编码
- 医疗保健管理部门的管理.
背景情况:
- 临床编码对于医疗保健业务至关重要,包括报销,资源分配,管理和医学研究.
- 准确的临床编码确保了适当的财政补偿,并支持有效的医疗管理.
- 临床文档的质量,特别是主页的完整性,显著影响编码准确性.
研究的目的:
- 评估临床编码的准确性,并确定影响其因素.
- 评估医生和临床编码人员之间的协作所产生的影响和益处.
- 调查文档质量,编码器性能和整体编码准确性之间的关系.
主要方法:
- 质量审计涉及24名医生和一名高级临床编码员.
- 利用国际疾病分类 (ICD) 准则和特定的主页准则进行准确性评估.
- 分析了323,320份医疗记录,比较了医生与临床编码员合作前后的编码准确度和校正率.
主要成果:
- 平均编码准确率为83.4%,质量差的主页导致89.9%的错误.
- 医生与临床编码器的合作使编码精度从78.9%提高到87.1%,校正率从52.0%提高到73.0%.
- 影响准确性的因素包括医疗记录的复杂性,首页质量,协作持续时间,编程人员专业,经验,工作参与度和周日.
结论:
- 医生与临床编码器的合作是提高临床编码准确性的有效策略.
- 虽然协作可以提高编码准确性,但它本身并不能提高医疗记录主页的质量.
- 首页质量和心理因素仍然是临床编码准确性的重要决定因素.
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