一种改善脓毒症记录与编码的简单措施。
A simple measure to improve sepsis documentation and coding.
作者信息
Arberry Jamie, Henry Zanya, Corrah Tumena
机构信息
Northwick Park Hospital, London, UK.
Northwick Park Hospital, London, UK
出版信息
Clin Med (Lond). 2021 May;21(3):222-225. doi: 10.7861/clinmed.2020-0868.
INTRODUCTION
Sepsis incidence and mortality are increasing, yet sepsis appears to be under-recognised and under-reported. Accurate recognition and coding of sepsis allows for appropriate funding and accurate epidemiological representation.
METHODS
We implemented a discharge summary template for all patients discharged from our infectious diseases service and analysed sepsis documentation and coding before and after its introduction.
RESULTS
Beforehand, we found that 59% of 29 patients had sepsis, yet only 10% had it documented on their discharge summary, and 17% had it coded. Following implementation of the template, 38% of 52 patients had sepsis documented, yet only 20% of these had it coded. After delivery of a training session to the coders regarding the importance of sepsis, 38% of patients with a diagnosis of sepsis had it coded.
DISCUSSION
Despite requiring ongoing education and encouragement of clinicians and coders, implementation of the template was quick, cheap and easy and improved sepsis coding.
引言
脓毒症的发病率和死亡率正在上升，但脓毒症似乎未得到充分认识和报告。准确识别和编码脓毒症有助于获得适当的资金支持，并能准确反映流行病学情况。
方法
我们为从感染性疾病科出院的所有患者实施了出院小结模板，并分析了该模板引入前后脓毒症的记录和编码情况。
结果
此前，我们发现29名患者中有59%患有脓毒症，但出院小结中记录脓毒症的仅占10%，编码的占17%。实施模板后，52名患者中有38%的脓毒症得到记录，但其中只有20%进行了编码。在向编码人员进行了关于脓毒症重要性的培训后，38%被诊断为脓毒症的患者进行了编码。
讨论
尽管需要对临床医生和编码人员进行持续教育和鼓励，但模板的实施快速、成本低且操作简便，改善了脓毒症的编码情况。
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