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Quality Analysis on International Classification of Disease Coding in a 3A Hospital 某三甲医院国际疾病分类编码质量分析
Chinese Medical Record English Edition Pub Date : 2013-12-03 DOI: 10.3109/23256176.2013.865893
Ying She, Ping Song
{"title":"Quality Analysis on International Classification of Disease Coding in a 3A Hospital","authors":"Ying She, Ping Song","doi":"10.3109/23256176.2013.865893","DOIUrl":"https://doi.org/10.3109/23256176.2013.865893","url":null,"abstract":"AbstractObjective. A quality analysis is performed on the coding of disease diagnosis in medical record home pages according to the coding principle of ICD-10, so as to improve the coding accuracy. Method. A total of 4,335 copies are randomly sampled from 108,363 medical records of our hospital, taken from the period between 2011 and 2012, and the disease coding is checked one by one. Result. A total of 261 out of 4,335 medical records have mistakes and the error rate is 6.0%. Conclusion. Coders should strengthen their study of medical knowledge as well as ICD-10 related knowledge, continuously broaden the width and the depth of their knowledge, enhance work responsibility and improve the accuracy of disease coding.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"55 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2013-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114471464","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 1
Analysis on Treatment Characteristics of 469 Cases of Alcoholic Patients in Emergency Observation, and the Countermeasures 469例酒精中毒患者急诊观察治疗特点及对策分析
Chinese Medical Record English Edition Pub Date : 2013-12-03 DOI: 10.3109/23256176.2013.865886
Dan-ping Li, Cai-jun Wu
{"title":"Analysis on Treatment Characteristics of 469 Cases of Alcoholic Patients in Emergency Observation, and the Countermeasures","authors":"Dan-ping Li, Cai-jun Wu","doi":"10.3109/23256176.2013.865886","DOIUrl":"https://doi.org/10.3109/23256176.2013.865886","url":null,"abstract":"AbstractObjective. The treatment characteristics of acute alcoholic patients in the emergency observation rooms are summarized and analyzed, and analyses of the experience summary and countermeasures are conducted, in combination with our practical work. Method. A total of 469 cases of alcoholic patients who received transfusion treatments in the emergency observation room of our hospital, from March 1, 2012 to February 28, 2013, are chosen, and the information such as gender, age, clinical features and duration of hospitalization, and so on, is recorded. The observations are classified and retrospective statistical analyses are performed according to the patients’ degree of alcoholism. Result. Most of the 469 cases of alcoholic patients receive treatment between 8 p.m. and 4 a.m., especially in summer and at the end of the year. The degrees of alcoholism are classified according to their clinical features. The duration of hospitalization for the serious alcoholic patients is as long as (12.17 ± 3.4) hour...","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"16 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2013-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126134360","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Bibliometric Analysis of International Classification of Diseases in China 中国《国际疾病分类》文献计量学分析
Chinese Medical Record English Edition Pub Date : 2013-12-03 DOI: 10.3109/23256176.2013.865896
Xiu-fang Li, Hui-hui Zuo, Bai Jin
{"title":"Bibliometric Analysis of International Classification of Diseases in China","authors":"Xiu-fang Li, Hui-hui Zuo, Bai Jin","doi":"10.3109/23256176.2013.865896","DOIUrl":"https://doi.org/10.3109/23256176.2013.865896","url":null,"abstract":"AbstractObjective. To understand the overall research situation of the International Classification of Diseases in China and provide certain reference for in-depth research. Methods. Articles related to ICD research from the China Academic Journal Network Publishing Database were retrieved, and a procedure of statistical analysis on the following aspects was carried out: number of published papers, authors and their institutions and regions, journals and funds. Results. A total of 1,443 related articles were found. Most authors had published only one ICD-related paper and the number of authors who had published three or more papers accounted for 8.40% of the total. The statistical results of the number of published papers showed that the authors from Zhanjiang Central People's Hospital had published the maximum related articles at the unit level; the number of publications from the Guangdong Province lay in the leading position of this field at the regional level, but there was a big difference between di...","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"64 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2013-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125110403","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Line of Thinking on Fracture Coding 骨折编码思路
Chinese Medical Record English Edition Pub Date : 2013-12-03 DOI: 10.3109/23256176.2013.865887
Chongliang Fang, Zhi-ming Ma, Hui Sun
{"title":"Line of Thinking on Fracture Coding","authors":"Chongliang Fang, Zhi-ming Ma, Hui Sun","doi":"10.3109/23256176.2013.865887","DOIUrl":"https://doi.org/10.3109/23256176.2013.865887","url":null,"abstract":"AbstractFractures include pathological and traumatic fractures; and a certain line of thinking should be followed when coding. The pathological fractures caused by osteoporosis should be coded to M80.-. The pathological fractures not caused by osteoporosis, if occurring in the spine, should be coded to M49.5*; those not occurring in the spine, if they are caused by a tumor, should be coded to M90.7*, while those not caused by a tumor should be coded to M84.4. In traumatic fractures, fatigue fractures of spine should be coded to M48.4, while those not of the spine should be coded to M84.3; fractures due to birth injury should be coded to P11.5 or P13.-; in general traumatic fractures, if the region of fractures is unspecified, the fractures should be coded to T08-T14, the fractures of multiple regions (cross-categories) should be coded to T02, multiple fractures of single region (cross-subcategories) should be coded to S-2.7, and single fractures should be coded to relevant subcategories in S-2 except for ...","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"21 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2013-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131635322","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Quality Survey of 621 Clinical Blood Transfusion Records 621份临床输血记录质量调查
Chinese Medical Record English Edition Pub Date : 2013-12-01 DOI: 10.3109/23256176.2013.881020
Yan Wu, Jiaohua Wang, Lingbo Li
{"title":"Quality Survey of 621 Clinical Blood Transfusion Records","authors":"Yan Wu, Jiaohua Wang, Lingbo Li","doi":"10.3109/23256176.2013.881020","DOIUrl":"https://doi.org/10.3109/23256176.2013.881020","url":null,"abstract":"AbstractObjective. To study the existing problems in blood transfusion records and make the blood transfusion records normative. Method. A total of 621 blood transfusion records, which were filed in our hospital between January 2010 and December 2012, were randomly sampled; we checked seven aspects, such as the homepages of the medical records, forms of informed consent for blood transfusion treatment, tests before blood transfusion, indications for blood transfusion, blood transfusion nursing records, adverse transfusion reactions, and evaluation of blood transfusion and the therapeutic effect. We calculated the defect rate and the qualified rate. Result. A total of 188 blood transfusion records were found to have varying degrees of defects. The proportion of defective records was 30.2%, 43 records among them had more than two defects, the proportion of defective records was 6.92%, a total of 352 defects were found, and statistics of the unqualified rate of each aspect were obtained. Conclusion. The bloo...","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"45 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2013-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123138208","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Design and Application of Document Management System of Electronic Medical Records 电子病历文件管理系统的设计与应用
Chinese Medical Record English Edition Pub Date : 2013-12-01 DOI: 10.3109/23256176.2013.881030
Shaosheng Su, Yaocheng Yang, Yuanyuan He, Yong Yang, Shujuan Zhang, M. Cheng
{"title":"Design and Application of Document Management System of Electronic Medical Records","authors":"Shaosheng Su, Yaocheng Yang, Yuanyuan He, Yong Yang, Shujuan Zhang, M. Cheng","doi":"10.3109/23256176.2013.881030","DOIUrl":"https://doi.org/10.3109/23256176.2013.881030","url":null,"abstract":"AbstractApplication of electronic medical records tends to be mature, and the use of electronic medical records for filing and consultation in a document form become an important aspect in medical record management, with the purposes of achieving paperless storage, integrated display and intelligent application of medical records. Based on Microsoft's .NET Platform framework, the article uses the Microsoft Visual Studio C# 2005 development tool to design an electronic medical record document management system which has the functions of automatically filing medical record documents, reviewing data and enabling online search and reading of medical records. The functions can improve the work efficiency, as well as medical record utilization and safety.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"44 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2013-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121613760","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Influence of Medical Record Home Page Writing on DRGs 病案首页书写对DRGs的影响
Chinese Medical Record English Edition Pub Date : 2013-12-01 DOI: 10.3109/23256176.2013.882568
Caihua Liu, Yongjun Xia, J. Qiu
{"title":"Influence of Medical Record Home Page Writing on DRGs","authors":"Caihua Liu, Yongjun Xia, J. Qiu","doi":"10.3109/23256176.2013.882568","DOIUrl":"https://doi.org/10.3109/23256176.2013.882568","url":null,"abstract":"AbstractObjective. To formulate corresponding management measures in response to the analysis on factors influencing the quality of DRGs raw data extraction, thereby achieving the ehffect of promoting the data quality of the medical record home page. Method. Some missing items in the collected medical record home page and actual problems in the DRGs grouping process are analyzed in a statistical manner. Result. The data analysis shows that the non-filling of medical record home page information, inconsistent transfer information of those with severe illness, and nonstandard writing of the diagnosis directly affect the quality of DRGs platform data extraction and the delayed grouping. After improvement measures are adopted, the status of some items which were not filled in the medical record home page is obviously improved in the fourth quarter compared with that in the third quarter, wherein the rate of omission in filling surgical levels decreases dramatically, from 12.34% to 9.26%, and the X2 statistica...","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"36 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2013-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127947450","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Analysis and Countermeasures for Writing Quality of Manuals of Medical Records in Outpatient and Emergency in Community Health Service Institutions 社区卫生服务机构门急诊病案手册编写质量分析及对策
Chinese Medical Record English Edition Pub Date : 2013-12-01 DOI: 10.3109/23256176.2013.882569
Jiu-sheng Wang, Peng Li, Lu Dai, Linshu Ye
{"title":"Analysis and Countermeasures for Writing Quality of Manuals of Medical Records in Outpatient and Emergency in Community Health Service Institutions","authors":"Jiu-sheng Wang, Peng Li, Lu Dai, Linshu Ye","doi":"10.3109/23256176.2013.882569","DOIUrl":"https://doi.org/10.3109/23256176.2013.882569","url":null,"abstract":"AbstractObjective. To formulate countermeasures by analyzing the defects in manuals of medical records in outpatient and emergency, in order to improve the quality of medical records. Method. The check and statistical analysis were performed according to Methods for the Administration of Beijing Community Health Assessment (Trial). Result. A total of 528 manuals of medical records in outpatient and emergency were checked at random, and defects of 119 medical records were identified. Conclusion. Methods for strengthening the education and training of general practitioners, establishing a sound performance appraisal system, implementing an accountability system, performing inspection and assessment regularly, enhancing the summary and communication, and performing continuous improvement, etc. should be adopted to improve the writing quality of manuals of medical records in outpatient and emergency by a variety of measures.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"54 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2013-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131478654","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Focusing on Patient Safety and Strengthening the Management of Connotative Quality of Nursing Documents 注重患者安全加强护理文件内涵质量管理
Chinese Medical Record English Edition Pub Date : 2013-12-01 DOI: 10.3109/23256176.2013.881031
Y. Xi, Yuqi Liu
{"title":"Focusing on Patient Safety and Strengthening the Management of Connotative Quality of Nursing Documents","authors":"Y. Xi, Yuqi Liu","doi":"10.3109/23256176.2013.881031","DOIUrl":"https://doi.org/10.3109/23256176.2013.881031","url":null,"abstract":"AbstractObjective. To check and analyze the section of contents involving patient safety in the nursing documents and to improve the management of the connotative quality of the nursing documents. Method. A total of five content items, such as a patient's fall, pressure sore, blood transfusion, implementation of medical advice and special records, were checked in combination with the writing requirements of the hospital's nursing documents, based on relevant regulations specified in the Basic Criterion of Documentation of the Medical Record (trial) issued by the Ministry of Health. Result. The problems were that the scores for fall and pressure sore were inaccurate or the measures were not in place. Conclusion. Checking the section of records in the nursing documents involving patient safety, revealed that the inspection of nursing documents cannot become a mere superficial phenomenon of the formal framework and should play a greater role in building up the quality of nursing connotation.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"128 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2013-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123950227","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Design and Application of Medical Records Tracing System 病案追溯系统的设计与应用
Chinese Medical Record English Edition Pub Date : 2013-12-01 DOI: 10.3109/23256176.2013.881035
Wei He, Yankai Ma, Yunna Ma, Hai-Hong Jiang
{"title":"Design and Application of Medical Records Tracing System","authors":"Wei He, Yankai Ma, Yunna Ma, Hai-Hong Jiang","doi":"10.3109/23256176.2013.881035","DOIUrl":"https://doi.org/10.3109/23256176.2013.881035","url":null,"abstract":"AbstractIn the situation of digital management of medical records, the application of the medical record tracing system has changed the traditional medical record circulation patterns and has optimized the medical record circulation. The results of the research and analysis show that the time needed for each link in medical record circulation is significantly shortened after the application of the tracing system; the time taken to provide the services of lending and copying medical records is shortened, and the errors are reduced; doctors, patients or their family members, insurance companies and judicial departments are satisfied with the medical record service, and the satisfaction is improved significantly. It indicates that the application of the medical record tracing system improves the work efficiency of the medical record room and the service quality in lending and copying medical records, and promotes the scientific and effective development of medical record management.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"28 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2013-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126132796","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
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