摘要
目的本研究通过构建完善合理的病案编码绩效考核体系,充分调动编码工作者的主观能动性,促进医院高质量发展。方法以某三甲医院2024年6月份11名编码员工作质量监测指标进行绩效考核模型数据实践,运用实地调查、文献查阅、专家咨询法与层次分析法等科学方法,从工作份额、质量控制、学习提升三个维度建立病案编码绩效考核体系。结果以月度为单位周期纳入13项指标,涵盖编码病案份数(2.046%)、疾病编码条数(4.131%)、手术或操作编码条数(4.131%)、质控病案份数(6.527%)、额外工作(3.195%)、主要诊断编码正确率(25.343%)、主要手术编码正确率(17.561%)、主要诊断编码非残余类目占比(7.479%)、住院病案首页质控平均得分(8.081%)、病案及时完成率(6.018%)、参加编码学习次数(3.799%)、组织编码培训次数(8.458%)和编码知识考核情况(3.232%)。显示绩效总分最高者(编码员A)在质量控制和学习提升指标表现突出。结论绩效考核体系通过量化病案指标可充分考虑到病案编码管理工作内涵的复杂性,客观反映编码员工作效率与质量,有效调动工作积极性,挖掘病案编码潜力,为医院病案首页数据质量提升及高质量发展提供科学依据。
Objectives This study aims to construct a complete and reasonable medical record coding performance appraisal system to fully mobilize the subjective initiative of coding workers and promote the high-quality development of hospitals.Methods This paper used the work quality monitoring indicators of 11 coders in a tertiary hospital in June 2024 to conduct a performance appraisal model data practice,and used scientific methods such as field investigation,literature review,expert consultation and hierarchical analysis to establish a medical record coding performance appraisal system from three dimensions:work share,quality control,and learning improvement.Results Thirteen indicators were included on a monthly basis,covering the number of coded medical records(2.046%),the number of disease codes(4.131%),the number of surgery or operation codes(4.131%),the number of quality control medical records(6.527%),extra work(3.195%),the accuracy of major diagnosis codes(25.343%),the accuracy of major surgery codes(17.561%),the proportion of non-residual categories of major diagnosis codes(7.479%),the average quality control score of the inpatient medical record homepage(8.081%),the timely completion rate of medical records(6.018%),the number of times participating in coding learning(3.799%),the number of times organizing coding training(8.458%)and the coding knowledge assessment(3.232%).The result showed that the one with the highest total performance score(Coder A)performed outstandingly in the quality control and learning improvement indicators.Conclusions The performance appraisal system can fully take into account the complexity of the connotation of medical record coding management by quantifying medical record indicators,objectively reflect the work efficiency and quality of coders,effectively mobilize work enthusiasm,tap the potential of medical record coding,and provide a scientific basis for improving the data quality of the hospital's medical record front page and high-quality development.
作者
林家荣
郭孟玲
郑娟娟
孙允宗
蔡雪玉
曾荣东
Lin Jiarong;Guo Mengling;Zheng Juanjuan;Sun Yunzong;Cai Xueyu;Zeng Rongdong(The First Hospital of Quanzhou Affiliated to Fujian Medical University,Quanzhou 362000,Fujian Province,China;不详)
出处
《中国病案》
2025年第7期20-23,共4页
Chinese Medical Record
关键词
病案编码
绩效考核
层次分析法
指标体系
Medical record code
Performance evaluation
Analytic hierarchy process
Indicator system
