产科和妇科连续性诊所中一份文档记录与编码课程的影响
The impact of a documentation and coding curriculum in an obstetrics and gynecology continuity clinic.
作者信息
Gala Rajiv B, Chiang Seine
机构信息
Department of Obstetrics and Gynecology, Ochsner Clinic Foundation, and The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.
出版信息
Ochsner J. 2012 Winter;12(4):354-8.
BACKGROUND
The goal of this study was to determine how increasing levels of residency training as well as a documentation and coding curriculum affected coding accuracy in the continuity clinic setting.
METHODS
All postgraduate year (PGY) 2 through PGY 4 residents (n=22) participated in a mandatory 3-module curriculum. Residents completed mock charge tickets in the obstetrics and gynecology continuity clinic for every patient encountered 1 month before and 1 month after the curriculum. An audit of 5 random charts per resident (n=110) compared chart documentation with the billing levels noted on the mock charge tickets.
RESULTS
We found a significant reduction in the number of undercoded charts for everyone except PGY 4 residents. In addition, all residents correctly coded more charts after the curriculum (from 30 to 46 charts, P=0.03).
CONCLUSION
The first phase of our documentation and coding curriculum study demonstrated that significant improvements in coding accuracy are achieved when implemented among PGY 2 and PGY 3 residents. Refinements in the basic foundation of knowledge may help prevent overcoding errors.
背景
本研究的目的是确定住院医师培训水平的提高以及文档记录和编码课程如何影响连续性诊所环境中的编码准确性。
方法
所有二年级至四年级的住院医师（n = 22）参加了一个强制性的三模块课程。住院医师在课程开始前1个月和课程结束后1个月，针对妇产科连续性诊所遇到的每位患者完成模拟收费单。对每位住院医师的5份随机病历（n = 110）进行审核，将病历文档与模拟收费单上记录的计费水平进行比较。
结果
我们发现，除了四年级住院医师外，其他所有人编码不足的病历数量都显著减少。此外，所有住院医师在课程结束后正确编码的病历更多（从30份增加到46份，P = 0.03）。
结论
我们的文档记录和编码课程研究的第一阶段表明，在二年级和三年级住院医师中实施该课程后，编码准确性有显著提高。基础知识的细化可能有助于防止过度编码错误。
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