摘要
目的 分析广州市某三甲中医院血清阴性脊柱关节病ICD-10编码的使用情况,为提高编码准确率提供参考。方法 利用广东省医疗机构病案统计管理系统检索2018年1月1日-2020年12月31日主要诊断编码为血清阴性脊柱关节病的病例共736份,逐份查阅病案,核对住院病案首页主要诊断编码,统计疾病编码错误例数,分析编码错误原因。结果 主要编码错误病案共96份,总错误率13.04%。其中,强直性脊柱炎、银屑病性关节炎因发病年龄不同而分类到不同编码导致出现编码错误,前者错误率最高,为17.49%。结论 血清阴性脊柱关节病因、发病年龄、持续时间不同分类也不同,编码员应明确血清阴性脊柱关节病的具体类型、发病年龄及持续时间等关键因素,再予以精确地分类和编码。
Objectives To analyze the use of ICD-10 coding for seronegative spondyloarthritis in a Three A and Tertiary Hospital of Traditional Chinese Medicine in Guangzhou,and provide reference for improving the accuracy of coding.Methods A total of 736 cases of seronegative spondyloarthropathy were retrieved from The medical records statistics management system of medical institutions in Guangdong Province from January 1 st,2018 to December 31 st,2020.The medical records were checked one by one,the main diagnostic codes of the first page of the inpatient medical records were checked,the number of disease coding errors were counted,and the causes of coding errors were analyzed.Results There were 96 cases with coding errors,and the total error rate was 13.04%.Among them,ankylosing spondylitis and psoriatic arthritis were classified into different codes due to different ages of onset,resulting in coding errors.The former had the highest error rate(17.49%).Conclusions The etiology,age of onset and duration of seronegative spondyloarthropathy were classified in different ways.Coders should clarify the specific type,age of onset and duration of seronegative spondyloarthropathy,and then accurately classify and code it.
作者
洪倩
李生
Hong Qian;Li Sheng(The First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine,Guangzhou 510000,Guangdong Province,China;不详)
出处
《中国病案》
2022年第3期27-29,共3页
Chinese Medical Record
