摘要
出院诊断疾病编码是病案首页中最重要的内容之一,提高其准确率首先要有正确的标准。通过查阅某院2017—2019年所有出院主要诊断ICD-10编码为亚目Q85.9未特指的斑痣性错构瘤病的住院病案,发现几乎每份病案的编码Q85.9都与医师诊断不符,错将某个器官的错构瘤分类于错构瘤病(或斑痣性错构瘤病),而后者是累及多个器官系统的综合征;指出错误的主要原因在于《疾病分类代码国家临床版2.0》对Q85.9的扩展是不合理的。提出错构瘤的正确编码,并建议《疾病分类代码国家临床版》对相关编码进行调整,以确保病案首页编码数据的准确性、同质性,使病案首页信息能够得到更好的利用。
The disease classification code for discharge diagnosis is one of the most important items in the front sheet of medical records. A well-established standard is needed for improving the accuracy of coding. The author retrieved all the inpatient medical records from a hospital between 2017 and 2019 with the ICD-10 code Q85.9 as the primary diagnostic code and discovered that the code was used incorrectly in almost every case, being inconsistent with doctor’s diagnosis. Coders confused hamartoma with hamartosis(or phakomatosis). In fact, the latter is a syndrome which involves several organs or systems, while the former only involves one organ or type of tissue. Then the author pointed out that the expansion codes of Q85.9 in the National Clinical Coding Database of Classification of Diseases Edition 2.0 are inappropriate and therefore responsible for coders’ misuse of these codes. Suitable codes have been proposed for hamartoma. The expansion codes of Q85.9 in the national database should be revised, so as to ensure the accuracy and homogeneity of coding, which will lead to better utilization of the information in the front sheet of medical records.
作者
姜珺
史晓凤
鲁磊
JIANG Jun;SHI Xiaofeng;LU Lei(The First Affiliated Hospital with Nanjing Medical University,Nanjing 210029,China;不详)
出处
《现代医院》
2021年第5期778-780,共3页
Modern Hospitals
