摘要
目的探讨影响脑血管疾病编码准确性的因素,以便提出整改措施.方法调取某院2017年1月1日-2017年12月31日主诊断编码ICD-10范围在I60~I69的住院病案共2170例,依据ICD-10国际疾病分类编码规则分析编码的准确情况,查找编码错误原因.结果2170份住院病案中,问题编码病案351份,错误率16.18%.问题编码的主要类型为未按照ICD-10规则合并编码占26.78%,主要诊断与诊断依据的检查报告不符占20.23%,主要诊断与主要手术介入操作不符占19.09%,未按照临床解剖部位编码占9.97%,照搬医师书写的诊断编码占16.81%,其他诊断错误选择占7.12%.结论依据脑血管病编码错误的原因提出提高编码准确性的整改措施,以期减少在脑血管病编码工作中类似的编码错误,提高脑血管病编码的正确率.
Objective To discuss the factors that affect the coding accuracy of cerebrovascular diseases and propose corrective measures. Methods Review 2170 discharge medical records of a hospital with the main diagnostic code ICD-10 in the range of I60-I69 from January 1, 2017 to December 31, 2017, and analyze the reasons for the wrong coding according to the ICD-10 international disease classification coding rules. Results Among all 2170 discharged medical records, 351 were problem-coded medical records(error rate 16.18%). The main types of problem codes were failure to combine codes in accordance with ICD-10 rules(26.78%), discrepancies between main diagnosis and diagnostic basis(20.23%), discrepancies between main diagnosis and main surgical intervention(19.09%), failure to follow clinical anatomic site codes(9.97%), diagnostic codes written by doctors(16.81%), and other diagnostic errors(7.12%). Conclusion According to the causes of coding errors in cerebrovascular diseases, this paper puts forward some corrective measures to improve the accuracy of coding, in order to reduce similar coding errors in cerebrovascular diseases and improve the correct rate of coding in cerebrovascular diseases.
作者
邓雪华
陈斌
Deng Xuehua;Chen Bin(Information Center of The First People's Hospital of Hangzhou,Hangzhou 310006,Zhejiang Province,China)
出处
《中国病案》
2021年第6期32-34,共3页
Chinese Medical Record
关键词
脑血管疾病
编码
疾病分类
Cerebrovasc:ular disease
Coding
Disease classification
