湖南省2009年医疗机构死亡病例报告质量评价

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目的对湖南省医疗机构死亡病例网络报告系统报告质量和现状进行评估。方法使用县(区)报告率、单位报告率、报告及时性、报告合格率、审核率、审核及时性、审核合格率、医疗机构报告死亡占总人群死亡的比例、县及县以上医疗机构报告死亡占医院实际报告总死亡的比例、常见编码错误分布等指标,对全省2009年医疗机构死亡病例报告情况进行评价。结果全省县(区)报告率为100.00%,单位报告率为72.68%;全省平均审核率为100%。全省平均报告合格率为99.89%,平均审核合格率为99.96%;2009年通过医疗机构网络报告系统报告的死亡案例大约占同期全省总死亡数的56.55%;县及以上医院报告死亡数占医疗机构报告死亡数的11.30%;县及县以上医疗机构有明显编码错误的个案比例为2.45%。结论医疗机构死亡病例网络报告极大地提高了数据报告的及时性,报告死亡数据总体代表性逐步增强、报告质量逐步提高。目前存在比较普遍的问题是医疗机构死因报告和编码质量有待进一步提高,根本死因确定和编码培训工作待加强。 Objective To evaluate the quality and current status of the network reporting system for death cases in medical institutions in Hunan Province. Methods The county (district) reporting rate, unit reporting rate, reporting timeliness, reporting pass rate, audit rate, audit timeliness, audit pass rate, medical institutions report the proportion of deaths among the total population, the county and above medical institutions report The deaths accounted for the proportion of the total actual hospital deaths, the common coding error distribution and other indicators of the province in 2009 medical institutions to report the death of patients were evaluated. Results The report rate of the province (district) was 100.00% and the unit reported rate was 72.68%. The average examination rate of the province was 100%. The average passing rate of the province was 99.89%, with an average passing rate of 99.96%. In 2009, the death rate reported by the medical institution network reporting system accounted for about 56.55% of the total number of deaths in the province in the same period. The number of deaths reported in hospitals at or above the county level Accounting for 11.30% of the reported number of deaths in medical institutions. The proportion of cases with obvious coding errors at the county and above medical institutions was 2.45%. Conclusion The network report of death cases in medical institutions has greatly improved the timeliness of data reporting. The overall representativeness of the reported death data has been gradually enhanced and the quality of the reports gradually increased. At present, the more common problem is that the cause of death report and coding quality of medical institutions need to be further improved, and the work of determining the cause of death and coding training should be strengthened.
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