Establishment and application of quality control system for medical record front page coding in a hos-pital
10.3969/j.issn.1671-332X.2025.09.012
- VernacularTitle:某医院病案首页编码质量管理体系构建实践
- Author:
Junfeng LIU
1
;
Ziyi XIN
1
;
Sha LIU
1
;
Zhuochen LIN
1
;
Ying XIONG
1
Author Information
1. 中山大学附属第一医院 广东 广州 510080
- Publication Type:Journal Article
- Keywords:
Medical record front page;
Coding;
Quality;
Management system
- From:
Modern Hospital
2025;25(9):1360-1362
- CountryChina
- Language:Chinese
-
Abstract:
Objective Analyze the causes of coding issues in the inpatient medical record homepage of a hospital and propose targeted improvement measures,providing a reference basis for enhancing coding quality.Methods A total of 3 000 in-patient medical records from April 1,2021,to March 31,2022(pre-intervention group)and 2 900 records from April 1,2022,to March 31,2023(post-intervention group)were selected for analysis.Quality control statistics were performed on key indica-tors,including the overall coding accuracy rate,primary diagnosis coding,secondary diagnosis coding,primary surgical proce-dure coding,and other surgical procedure coding.Results After the implementation of intervention measures,the overall accu-racy rate of the first page coding of medical records increased from 80.77％to 86.72％(P＜0.001).While,the accuracy rate for primary diagnosis coding improved from 96.90％to 98.07％(P＜0.05).The secondary diagnosis coding accuracy showed significant enhancement from 87.48％to 92.26％(P＜0.001),and primary surgical procedure coding accuracy rose from 96.50％to 98.34％(P＜0.001).Although other surgical procedure coding demonstrated improvement,the difference was not statistically significant(P＞0.05).Conclusion Through a series of measures—including standardized training for coders,es-tablishing a robust quality control system,and adopting advanced information technology—both the professionalism of coders and coding efficiency were enhanced.These interventions effectively reduced coding defects and improved the quality of medical re-cord homepage coding.
