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Quality Analysis on International Classification of Disease Coding in a 3A Hospital 某三甲医院国际疾病分类编码质量分析
Pub Date : 2013-12-03 DOI: 10.3109/23256176.2013.865893
Ying She, Ping Song
AbstractObjective. A quality analysis is performed on the coding of disease diagnosis in medical record home pages according to the coding principle of ICD-10, so as to improve the coding accuracy. Method. A total of 4,335 copies are randomly sampled from 108,363 medical records of our hospital, taken from the period between 2011 and 2012, and the disease coding is checked one by one. Result. A total of 261 out of 4,335 medical records have mistakes and the error rate is 6.0%. Conclusion. Coders should strengthen their study of medical knowledge as well as ICD-10 related knowledge, continuously broaden the width and the depth of their knowledge, enhance work responsibility and improve the accuracy of disease coding.
AbstractObjective。根据ICD-10编码原则,对病案首页疾病诊断编码进行质量分析,提高编码精度。方法。从我院2011 - 2012年108363份病历中随机抽取4335份,逐条核对疾病编码。结果。4335份病历中有261份存在错误,错误率为6.0%。结论。编码员应加强医学知识和ICD-10相关知识的学习,不断拓宽知识的广度和深度,增强工作责任心,提高疾病编码的准确性。
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引用次数: 1
Analysis on Treatment Characteristics of 469 Cases of Alcoholic Patients in Emergency Observation, and the Countermeasures 469例酒精中毒患者急诊观察治疗特点及对策分析
Pub Date : 2013-12-03 DOI: 10.3109/23256176.2013.865886
Dan-ping Li, Cai-jun Wu
AbstractObjective. The treatment characteristics of acute alcoholic patients in the emergency observation rooms are summarized and analyzed, and analyses of the experience summary and countermeasures are conducted, in combination with our practical work. Method. A total of 469 cases of alcoholic patients who received transfusion treatments in the emergency observation room of our hospital, from March 1, 2012 to February 28, 2013, are chosen, and the information such as gender, age, clinical features and duration of hospitalization, and so on, is recorded. The observations are classified and retrospective statistical analyses are performed according to the patients’ degree of alcoholism. Result. Most of the 469 cases of alcoholic patients receive treatment between 8 p.m. and 4 a.m., especially in summer and at the end of the year. The degrees of alcoholism are classified according to their clinical features. The duration of hospitalization for the serious alcoholic patients is as long as (12.17 ± 3.4) hour...
AbstractObjective。结合我们的实际工作,对急诊观察室急性酒精患者的治疗特点进行总结分析,并对经验总结和对策进行分析。方法。选取2012年3月1日至2013年2月28日在我院急诊观察室接受输血治疗的酗酒患者469例,记录其性别、年龄、临床特征、住院时间等信息。对观察结果进行分类,并根据患者酒精中毒程度进行回顾性统计分析。结果。在469例酗酒患者中,大多数在晚上8点至凌晨4点之间接受治疗,特别是在夏季和年底。酒精中毒的程度是根据他们的临床特征来分类的。重度酒精中毒患者住院时间长达(12.17±3.4)h。
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引用次数: 0
Bibliometric Analysis of International Classification of Diseases in China 中国《国际疾病分类》文献计量学分析
Pub Date : 2013-12-03 DOI: 10.3109/23256176.2013.865896
Xiu-fang Li, Hui-hui Zuo, Bai Jin
AbstractObjective. To understand the overall research situation of the International Classification of Diseases in China and provide certain reference for in-depth research. Methods. Articles related to ICD research from the China Academic Journal Network Publishing Database were retrieved, and a procedure of statistical analysis on the following aspects was carried out: number of published papers, authors and their institutions and regions, journals and funds. Results. A total of 1,443 related articles were found. Most authors had published only one ICD-related paper and the number of authors who had published three or more papers accounted for 8.40% of the total. The statistical results of the number of published papers showed that the authors from Zhanjiang Central People's Hospital had published the maximum related articles at the unit level; the number of publications from the Guangdong Province lay in the leading position of this field at the regional level, but there was a big difference between di...
AbstractObjective。了解《国际疾病分类》在中国的总体研究情况,为深入研究提供一定的参考。方法。检索中国学术期刊网络出版数据库中与ICD研究相关的文章,对发表论文数、作者及其所在机构和地区、期刊和基金等方面进行统计分析。结果。共发现1443篇相关文章。大多数作者只发表过一篇icd相关论文,发表过三篇及以上论文的作者占总数的8.40%。论文发表数统计结果显示,湛江市中心人民医院在单位层面发表的相关文章最多;广东省在该领域的出版物数量在区域层面上处于领先地位,但两地之间的差异较大。
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引用次数: 0
Line of Thinking on Fracture Coding 骨折编码思路
Pub Date : 2013-12-03 DOI: 10.3109/23256176.2013.865887
Chongliang Fang, Zhi-ming Ma, Hui Sun
AbstractFractures include pathological and traumatic fractures; and a certain line of thinking should be followed when coding. The pathological fractures caused by osteoporosis should be coded to M80.-. The pathological fractures not caused by osteoporosis, if occurring in the spine, should be coded to M49.5*; those not occurring in the spine, if they are caused by a tumor, should be coded to M90.7*, while those not caused by a tumor should be coded to M84.4. In traumatic fractures, fatigue fractures of spine should be coded to M48.4, while those not of the spine should be coded to M84.3; fractures due to birth injury should be coded to P11.5 or P13.-; in general traumatic fractures, if the region of fractures is unspecified, the fractures should be coded to T08-T14, the fractures of multiple regions (cross-categories) should be coded to T02, multiple fractures of single region (cross-subcategories) should be coded to S-2.7, and single fractures should be coded to relevant subcategories in S-2 except for ...
骨折包括病理性骨折和外伤性骨折;在编码时应该遵循一定的思路。骨质疏松引起的病理性骨折应编码为m80 -。非骨质疏松引起的病理性骨折,如果发生在脊柱,应编码为M49.5*;非发生在脊柱的,如果是肿瘤引起的,编码为M90.7*,非肿瘤引起的编码为M84.4 *。外伤性骨折中,脊柱的疲劳骨折编码为M48.4,非脊柱的疲劳骨折编码为M84.3;产伤骨折应编码至P11.5或p13。-;对于一般创伤性骨折,如果骨折区域未明确,骨折编码为T08-T14,多区域骨折(交叉分类)编码为T02,单区域多骨折(交叉分类)编码为S-2.7,单区域骨折除…
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引用次数: 0
Quality Survey of 621 Clinical Blood Transfusion Records 621份临床输血记录质量调查
Pub Date : 2013-12-01 DOI: 10.3109/23256176.2013.881020
Yan Wu, Jiaohua Wang, Lingbo Li
AbstractObjective. To study the existing problems in blood transfusion records and make the blood transfusion records normative. Method. A total of 621 blood transfusion records, which were filed in our hospital between January 2010 and December 2012, were randomly sampled; we checked seven aspects, such as the homepages of the medical records, forms of informed consent for blood transfusion treatment, tests before blood transfusion, indications for blood transfusion, blood transfusion nursing records, adverse transfusion reactions, and evaluation of blood transfusion and the therapeutic effect. We calculated the defect rate and the qualified rate. Result. A total of 188 blood transfusion records were found to have varying degrees of defects. The proportion of defective records was 30.2%, 43 records among them had more than two defects, the proportion of defective records was 6.92%, a total of 352 defects were found, and statistics of the unqualified rate of each aspect were obtained. Conclusion. The bloo...
AbstractObjective。研究输血记录中存在的问题,使输血记录规范化。方法。随机抽取2010年1月至2012年12月在我院备案的621例输血记录;我们检查了病历主页、输血治疗知情同意书、输血前检查、输血指征、输血护理记录、输血不良反应、输血及治疗效果评价等七个方面。我们计算了不良率和合格率。结果。共有188份输血记录存在不同程度的缺陷。不良记录比例为30.2%,其中有2项以上不良记录43项,不良记录比例为6.92%,共发现不良352项,并对各方面的不合格率进行统计。结论。bloo……
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引用次数: 0
Design and Application of Document Management System of Electronic Medical Records 电子病历文件管理系统的设计与应用
Pub Date : 2013-12-01 DOI: 10.3109/23256176.2013.881030
Shaosheng Su, Yaocheng Yang, Yuanyuan He, Yong Yang, Shujuan Zhang, M. Cheng
AbstractApplication of electronic medical records tends to be mature, and the use of electronic medical records for filing and consultation in a document form become an important aspect in medical record management, with the purposes of achieving paperless storage, integrated display and intelligent application of medical records. Based on Microsoft's .NET Platform framework, the article uses the Microsoft Visual Studio C# 2005 development tool to design an electronic medical record document management system which has the functions of automatically filing medical record documents, reviewing data and enabling online search and reading of medical records. The functions can improve the work efficiency, as well as medical record utilization and safety.
摘要电子病案的应用趋于成熟,利用电子病案以文件形式进行归档和会诊成为病案管理的一个重要方面,以实现病案无纸化存储、一体化显示和智能化应用。本文基于微软的。net平台框架,使用Microsoft Visual Studio c# 2005开发工具,设计了一个电子病案文档管理系统,该系统具有自动归档病案文档、查看数据以及在线查询和阅读病案的功能。该功能可以提高工作效率,提高病历的利用率和安全性。
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引用次数: 0
Influence of Medical Record Home Page Writing on DRGs 病案首页书写对DRGs的影响
Pub Date : 2013-12-01 DOI: 10.3109/23256176.2013.882568
Caihua Liu, Yongjun Xia, J. Qiu
AbstractObjective. To formulate corresponding management measures in response to the analysis on factors influencing the quality of DRGs raw data extraction, thereby achieving the ehffect of promoting the data quality of the medical record home page. Method. Some missing items in the collected medical record home page and actual problems in the DRGs grouping process are analyzed in a statistical manner. Result. The data analysis shows that the non-filling of medical record home page information, inconsistent transfer information of those with severe illness, and nonstandard writing of the diagnosis directly affect the quality of DRGs platform data extraction and the delayed grouping. After improvement measures are adopted, the status of some items which were not filled in the medical record home page is obviously improved in the fourth quarter compared with that in the third quarter, wherein the rate of omission in filling surgical levels decreases dramatically, from 12.34% to 9.26%, and the X2 statistica...
AbstractObjective。针对影响DRGs原始数据提取质量的因素进行分析,制定相应的管理措施,从而达到提升病案首页数据质量的效果。方法。对收集到的病案首页的一些缺失项目和DRGs分组过程中存在的实际问题进行了统计分析。结果。数据分析表明,病案首页信息不填写、重症患者转诊信息不一致、诊断书写不规范等问题直接影响DRGs平台数据提取质量和分组延迟。采取改善措施后,四季度病案首页部分未填写项目的情况较三季度有明显改善,其中外科水平填写的遗漏率从12.34%大幅下降至9.26%,X2统计量为…
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引用次数: 0
Analysis and Countermeasures for Writing Quality of Manuals of Medical Records in Outpatient and Emergency in Community Health Service Institutions 社区卫生服务机构门急诊病案手册编写质量分析及对策
Pub Date : 2013-12-01 DOI: 10.3109/23256176.2013.882569
Jiu-sheng Wang, Peng Li, Lu Dai, Linshu Ye
AbstractObjective. To formulate countermeasures by analyzing the defects in manuals of medical records in outpatient and emergency, in order to improve the quality of medical records. Method. The check and statistical analysis were performed according to Methods for the Administration of Beijing Community Health Assessment (Trial). Result. A total of 528 manuals of medical records in outpatient and emergency were checked at random, and defects of 119 medical records were identified. Conclusion. Methods for strengthening the education and training of general practitioners, establishing a sound performance appraisal system, implementing an accountability system, performing inspection and assessment regularly, enhancing the summary and communication, and performing continuous improvement, etc. should be adopted to improve the writing quality of manuals of medical records in outpatient and emergency by a variety of measures.
AbstractObjective。通过分析门急诊病案手册存在的缺陷,制定对策,以提高病案质量。方法。按照《北京市社区健康评估管理方法(试行)》进行检验和统计分析。结果。随机抽查门急诊病历手册528份,发现缺陷119份。结论。应采取加强全科医生教育培训、建立健全绩效考核制度、实行问责制、定期检查考核、加强总结沟通、持续改进等方法,通过多种措施提高门急诊病案手册的编写质量。
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引用次数: 0
Focusing on Patient Safety and Strengthening the Management of Connotative Quality of Nursing Documents 注重患者安全加强护理文件内涵质量管理
Pub Date : 2013-12-01 DOI: 10.3109/23256176.2013.881031
Y. Xi, Yuqi Liu
AbstractObjective. To check and analyze the section of contents involving patient safety in the nursing documents and to improve the management of the connotative quality of the nursing documents. Method. A total of five content items, such as a patient's fall, pressure sore, blood transfusion, implementation of medical advice and special records, were checked in combination with the writing requirements of the hospital's nursing documents, based on relevant regulations specified in the Basic Criterion of Documentation of the Medical Record (trial) issued by the Ministry of Health. Result. The problems were that the scores for fall and pressure sore were inaccurate or the measures were not in place. Conclusion. Checking the section of records in the nursing documents involving patient safety, revealed that the inspection of nursing documents cannot become a mere superficial phenomenon of the formal framework and should play a greater role in building up the quality of nursing connotation.
AbstractObjective。对护理文件中涉及患者安全的部分内容进行审核分析,提高对护理文件内涵质量的管理。方法。根据卫生部《病案文件编制基本规范(试行)》的相关规定,结合医院护理文件的书写要求,对患者跌倒、压疮、输血、医嘱执行情况、特殊记录等5个内容项目进行检查。结果。问题是跌倒和压疮的分数不准确或措施不到位。结论。通过对护理文件中涉及患者安全的记录部分的检查,发现护理文件的检查不能成为形式框架的表面现象,而应在构建护理质量内涵方面发挥更大的作用。
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引用次数: 0
Design and Application of Medical Records Tracing System 病案追溯系统的设计与应用
Pub Date : 2013-12-01 DOI: 10.3109/23256176.2013.881035
Wei He, Yankai Ma, Yunna Ma, Hai-Hong Jiang
AbstractIn the situation of digital management of medical records, the application of the medical record tracing system has changed the traditional medical record circulation patterns and has optimized the medical record circulation. The results of the research and analysis show that the time needed for each link in medical record circulation is significantly shortened after the application of the tracing system; the time taken to provide the services of lending and copying medical records is shortened, and the errors are reduced; doctors, patients or their family members, insurance companies and judicial departments are satisfied with the medical record service, and the satisfaction is improved significantly. It indicates that the application of the medical record tracing system improves the work efficiency of the medical record room and the service quality in lending and copying medical records, and promotes the scientific and effective development of medical record management.
摘要在病案数字化管理的形势下,病案溯源系统的应用改变了传统的病案流通模式,优化了病案流通。研究分析结果表明,病案溯源系统应用后,病案流转各环节所需时间明显缩短;缩短了提供病历出借、复印服务的时间,减少了差错;医生、患者或家属、保险公司和司法部门对病案服务满意,满意度显著提高。表明病案溯源系统的应用,提高了病案室的工作效率和病案出借、复制的服务质量,促进了病案管理的科学有效发展。
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引用次数: 0
期刊
Chinese Medical Record English Edition
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