摘要
目的通过对前置胎盘病例进行分析,探讨准确对前置胎盘进行国际疾病分类编码和主要诊断选择。方法收集2015年1月-2018年8月珠海市某三甲医院疾病编码为O44.000-O44.103前置胎盘出院病案共201份,调阅收集病案的病历记录和检查报告等资料,分析前置胎盘编码。结果前置胎盘的疾病编码错误22例,主要诊断选择错误共18例,错误率较高。结论编码人员不但要熟悉前置胎盘的ICD-10疾病分类,还要掌握临床各种诊断类型及相关医学知识,如前置胎盘状态、胎盘低置、凶险性前置胎盘等,注意前置胎盘是否伴有产前、产时、产后出血。用ICD思维综合分析临床的诊断及本次住院主要处理的问题,正确选择主要的诊断和疾病编码。
Objectives To explore methods of improving the accuracy of ICD-10 classification in placenta previa through a statistical analysis of placenta previa cases. Methods The data was collected from the discharged cases of placenta previa from January 2015 to August 2018 in a Three A and Tertiary Hospital in Zhuhai, the medical records and examination reports were also reviewed to analyse the problems of placenta previa coding.Results There were 22 cases of illness coding errors found in the total of 201 discharged cases of placenta previa including 18 of the cases had significant diagnostic errors. Conclusions In order to reduce ICD-10 classification error in placenta previa, medical record administrators needed be familiar with the classification of the diagnosis,to understand the relevant medical knowledge of clinical diagnoses, such as placenta previa status, dangerous placenta previa, low placenta implantation, in addition to a comprehensive analysis of the clinical diagnosis and the main presenting problems during hospitalisation. The correct choice of the primary diagnosis and disease code would facilitate the accuracy of classification.
作者
吴妙婷
文建珍
许萍
徐素梅
Wu Miaoting;Wen Jianzhen;Xu Ping;Xu Sumei(The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, Guangdong Province, China)
出处
《中国病案》
2019年第7期35-37,共3页
Chinese Medical Record
