Garavand Ali, Esmaeeli Erfan, Bahador Fatemeh, Sabahi Azam
Department of Health Information Technology, School of Allied Medical Sciences, Lorestan University of Medical Sciences, Khorramabad, Iran.
Department of Medical Informatics, Tehran University of Medical Sciences, Tehran, Iran.
Tanaffos. 2024 Feb;23(2):189-197.
During the COVID-19 pandemic, disease coding significantly influenced national and international strategies for prevention, treatment, and control. This study aimed to assess the factors influencing COVID-19 records' coding errors in teaching hospitals in South Khorasan province.
In 2022, researchers conducted a cross-sectional study in South Khorasan Province, Iran. Data was gathered using a self-developed questionnaire distributed among medical coders in all hospitals. Descriptive statistics were employed in the data analysis using SPSS version 19.
The study's results showed that non-observance of diagnostic principles by physicians (66 out of 92), a lack of specialized medical coding specialists (52 out of 92), and the use of ambiguous and non-standard abbreviations (51 out of 92) were the most significant factors affecting COVID-19 coding errors. Among the three main factors affecting COVID-19 records' coding errors, factors related to the medical coder (47.66 out of 92), factors related to healthcare providers (29.8 out of 92), and organizational and environmental factors (21.4 out of 92) were the most significant.
This study revealed that multiple factors contribute to coding errors in COVID-19 records, with the most critical being physicians' non-adherence to diagnostic principles, the shortage of medical coding specialists, the use of unclear and non-standard abbreviations, and the absence of COVID-19 coding continuing education. Therefore, we recommend conducting workshops on diagnosis and coding for medical coders, particularly emphasizing the precise coding of COVID-19 records.
在新冠疫情期间,疾病编码对国家和国际预防、治疗及控制策略产生了重大影响。本研究旨在评估影响霍拉桑省南部教学医院新冠记录编码错误的因素。
2022年,研究人员在伊朗霍拉桑省南部开展了一项横断面研究。数据通过自行编制的问卷收集,分发给所有医院的医学编码员。使用SPSS 19版进行数据分析时采用了描述性统计方法。
研究结果显示,医生未遵守诊断原则(92例中有66例)、缺乏专业医学编码专家(92例中有52例)以及使用模糊和不标准的缩写(92例中有51例)是影响新冠编码错误的最主要因素。在影响新冠记录编码错误的三个主要因素中,与医学编码员相关的因素(92例中有47.66例)、与医疗服务提供者相关的因素(92例中有29.8例)以及组织和环境因素(92例中有21.4例)最为显著。
本研究表明,多种因素导致了新冠记录的编码错误,其中最关键的是医生不遵守诊断原则、医学编码专家短缺、使用不清晰和不标准的缩写以及缺乏新冠编码继续教育。因此,我们建议为医学编码员举办诊断和编码讲习班,特别强调新冠记录的精确编码。