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中文摘要: 目的：了解不同编码员特征对住院病案首页编码正确率的影响并提出改进建议，以提高病案编码质量，为推进医院数据统计、DRGs应用及医保付费改革等提供数据基础。方法：采用现状调查方法，分层随机抽取某院2019年10月1日-2019年10月31日住院病案520份，对住院病案首页编码质量进行评价，并采用χ2检验分析不同工作年限、专业背景、有无编码培训合格证等特征对编码正确率的影响。结果：≤5年、6~10年、11~20年、>20年工作年限编码员的主要手术/操作编码正确率分别为87.50%、89.89%、93.20%、77.59%，差异有统计学意义（Ρ=0.030）；其他手术/操作编码正确率分别为72.22%、79.41%、93.62%、69.57%，差异有统计学意义（Ρ=0.026）。病案管理学、统计学、卫生事业管理、护理学及其他专业编码员的其他手术/操作编码正确率分别为93.62%、71.70%、75.00%、75.00%，差异有统计学意义（Ρ=0.037）。有、无编码培训合格证编码员的主要诊断编码正确率分别为93.79%、88.26%，差异有统计学意义（Ρ=0.026）；其他手术/操作编码正确率分别为86.96%、70.24%，差异有统计学意义（Ρ=0.007）。结论：在主要诊断及手术/操作编码方面，工作年限11~20年、具有专业背景、经培训取得编码培训合格证的编码员编码正确率相对较高，提示工作年限、专业背景、有无编码培训合格证可影响编码质量，应加强编码专业人员引进及培训管理，提高编码质量，保障病案首页数据的准确性及可及性。
Abstract:Objectives：To understand the influence of different coder characteristics on the front page coding accuracy of discharged medical records and put forward improvement suggestions，in order to improve the coding quality of medical records，and provide data basis for hospital data statistics，the application of DRGs and the reform of medical insurance payment. Methods：By using the method of current investigation，520 medical records discharged in October 2019 were selected using stratified random sampling method to evaluate the front page coding quality in discharged medical records of coders at different levels，and analyze the influence of coding experience，professional background and code training certificate using χ2 test. Results：In the coders with ≤5 years，6~10 years，11~20 years or >20 years working experience，the coding accuracy of major operations/procedures were 87.50%，89.89%，93.20% and 77.59% respectively. The difference was statistically significant（Ρ=0.030）；The coding accuracy of other operations/procedures were 72.22%，79.41%，93.62% and 69.57% respectively. The difference was statistically significant（Ρ=0.026）.In the coders with medical record management，statistics，health management，nursing or other profession，the coding accuracy of other operations/procedures were 93.62%，71.70%，75.00% and 75.00% respectively. The difference was statistically significant（Ρ=0.037）. In the coders with or without code training certificate，the coding accuracy of the main diagnosis were 93.79% and 88.26% respectively. The difference was statistically significant（Ρ=0.026）；The coding accuracy of other operations/procedures were 86.96% and 70.24% respectively. The difference was statistically significant（Ρ=0.007）. Conclusions：The average coding accuracy of primary diagnosis and operations/procedures of the coders with11-20 years coding experience，professional background or code training certificate were higher than other personnel. It means that the coding experience，professional background and code training certificate could affect the coding quality. The introduction of coding professionals and coding training should be strengthened，to improve the coding quality，and ensure the accuracy and availability of the data on the front page of medical records.
keywords: ICD Coder Characteristics Coding Accuracy
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基金项目:南京大学医院管理研究所管理项目课题（NDYG2019003） 南京大学医院管理研究所管理项目课题（NDYG2019003）
引用文本：
陈建平,朱爱霞,吴植茆,吴良明*.编码员特征对住院病案首页编码正确率的影响△[J].江苏卫生事业管理,2022,33(4):446-450.
CHEN Jianping,ZHU Aixia,WU Zhimao,WU Liangming*.Influence of Coder Characteristics on the Coding Accuracy of the Front Page of Discharged Medical Records△[J].Jiangsu Health System Management,2022,33(4):446-450.
陈建平,朱爱霞,吴植茆,吴良明*.编码员特征对住院病案首页编码正确率的影响△[J].江苏卫生事业管理,2022,33(4):446-450.
CHEN Jianping,ZHU Aixia,WU Zhimao,WU Liangming*.Influence of Coder Characteristics on the Coding Accuracy of the Front Page of Discharged Medical Records△[J].Jiangsu Health System Management,2022,33(4):446-450.
