【摘要】 目的评价某医院疾病自动编码系统对编码员编码效率和编码质量的影响,为疾病自动编码系统在医院的推广提供参考。方法采集2017年8月1日-2018年1月31日出院的39 860份病案首页共204 665条疾病诊断作为对照组,构建疾病自动编码系统稳定后,采集2019年8月1日-2020年1月31日出院的39 207份病案首页共238 137条疾病诊断作为自动编码组,比较2组间的人均每月人工编码总数,应用完全随机抽样方法抽取对照组和自动编码组病案首页各1000份,比较2组编码总错误率。结果自动编码组平均编码成功率为85.8%,平均编码符合率为87.4%。自动编码组的人均每月人工编码总数(WilcoxonW=21,P=0.002)和疾病诊断编码错误率(χ~2=45.72,P<0.001)均明显低于对照组,差异有统计学意义。结论医院的疾病自动编码系统不仅能提高编码员编码效率,改善编码质量,而且能有效促进疾病诊断规范化。更多还原

【Abstract】 Objectives To evaluate the effect of hospital disease automatic coding system on coding efficiency and coding quality of coders, and provide reference for the promotion of hospital disease automatic coding system.Methods From August 1 st, 2017 to January 31 st, 2018, a total of 39,860 medical records with 204,665 disease diagnoses were collected as the control group. From August 1 st, 2019 to January 31 st, 2020, a total of 39,207 medical records with 238,137 disease diagnoses were collected as the automatic coding group. The total number of manual coding per person per month between the two groups was compared. A total of 1000 medical records were selected from the control group and the automatic coding group by complete random sampling, and the total coding error rate was compared between the two groups. Results The average coding success rate of the automatic coding group was 85.8%, and the average coding coincidence rate was 87.4%. The total number of manual codes per person per month in the automatic coding group(Wilcoxon W=21,P=0.002) and the code error rate of disease diagnosis(χ~2=45.72, P<0.001) were significantly lower than those in the control group. Conclusions The disease automatic coding system of the hospital could not only improve the coding efficiency of coders and improve the coding quality, but also effectively promote the standardization of disease diagnosis.更多还原