Construction of quality control system and diagnosis coding of obstetrical medical record homepage based on logical check rules
10.3969/j.issn.1671-332X.2025.09.011
- VernacularTitle:基于逻辑校验规则的产科病案首页质控体系构建及诊断编码问题研究
- Author:
Zhou XU
1
;
Zhengyu ZHANG
;
Yuan YUAN
;
Yu WANG
Author Information
1. 浙江大学医学院附属第一医院 浙江 杭州 310003
- Publication Type:Journal Article
- Keywords:
Obstetrics department;
Quality control;
Disease diagnosis;
ICD code
- From:
Modern Hospital
2025;25(9):1356-1359
- CountryChina
- Language:Chinese
-
Abstract:
Objective To improve the quality of diagnosis and coding on obstetric medical record home pages in our cit-y,identify major issues,and provide a basis for targeted training interventions.Methods Utilizing a medical record quality con-trol system and logic validation rules,we conducted verification and problem identification analysis on diagnosis and coding infor-mation from all obstetric medical record home pages throughout 2024 across five tertiary hospitals in the city.Results 40.37％of the front page of obstetric medical record had problems.The major problems included missing diagnosis(65.75％),wrong coding(25.02％)and wrong choice of main diagnosis(6.99％).Conclusion The establishment of logical validation rules based on the information on front pages of obstetric medical record can identify the problems in the diagnosis together with the coding of front page of obstetric medical record,which is conducive to targeted training of obstetrician and medical record coders,as well as improving the completeness and accuracy of the diagnosis and coding of the front page of obstetric medical record.
