Objective To encourage clinicians to code the major diagnosis of diseases, in order to improve the correct rate of disease major diagnosis coding. Methods We analyzed the data of major diagnostic codes by clinicians from January 2012 to June 2013. The group leader of the clinical treatment was designated to be responsible for the disease coding. Disease coders introduced knowledge of international classification of diseases to the clinical department according to the different characteristics of disease in each department and communicated with clinicians on the problems of disease coding. Then, we tried to find out whether this method could improve the correct rate of major diagnosis coding of diseases. Results The rate of disease major coding by clinicians of the whole hospital and pilot departments increased from 94.081% to 98.301%. The correct rate of disease major coding decreased from 75.824% to 67.483% and then reached 81.893%. The correct rate of disease major coding of the Department of Hematology was 83.824% in August 2012 and then decreased with the lowest rate of 68.025%; and the correct rate of disease major coding of the Department of Orthopedics increased rapidly and reached 90% in September 2012. Conclusions Through the leader of the clinical treatment being responsible for the disease coding and encouraging clinicians to code the main diagnosis of diseases, the accurate of disease major diagnosis coding has improved. Strengthening the communication between clinical and Medical Record Departments can help our hospital improve the quality of disease major diagnosis coding continuously.

Citation： LiaoGuirong, LuoJian, MoChunmei. Research on the Continuous Improvement of the Quality of Disease Major Diagnosis Coding by Clinicians in A Large Teaching Hospital. West China Medical Journal, 2016, 31(5): 963-967. doi: 10.7507/1002-0179.201600261 Copy