摘要
目的通过分析ICD-10中含有.9的残余类目编码的使用情况,寻找减少残余类目误用的方法,提高编码准确性。方法对某院2015年10-11月出院的6000份病案主要诊断进行编码,对含有.9的残余类目编码进行汇总分析。结果 6000份病案中有2100(35%)份病案使用了残余类目,其中有420份(7%)残余类目编码使用不可避免,有1680份(28%)残余类目编码属于误用。结论残余类目.9编码在编码中的误用情况较为严重,编码员除了提高自身编码水平外,还应该建立与临床医师沟通机制,同时对临床医师进行疾病分类知识培训,通过多项举措的实施以减少残余类目.9的使用,提高疾病编码的准确性。?
Objective Through analyze the application situation of remnant items of coding included ＂.9＂ in ICD-10, to look for methods to decrease the misapplication of remnant items and improve the accuracy of coding.Methods To conduct coding on the principle diagnosis of 6000 cases of medical records discharged from October to November 2015 of the hospital, and make summary analysis on the items included ＂.9＂ in the remnant items of coding. Results There were 2100（35%） in 6000 cases of medical records applied remnant items, in which 420（7%）cases were inevitable and 1680（28%） were misapplication. Conclusions The misapplication situation of ＂.9＂ coding was serious, the coders should not only improve their own coding level, but should also establish communication mechanism with clinical doctors, perform training on the diseases classification knowledge to clinical doctors. To decrease the application of remnant items ＂.9＂ through the implementation of multiple measures, as well as improve the accuracy of diseases coding.
出处
《中国病案》
2016年第7期21-23,共3页
Chinese Medical Record
关键词
残余类目
疾病编码
误用
准确性
Remnant items
Disease coding
Misapplication
Accuracy
