摘要
目的通过分析患者本次住院就医的主要原因,探讨骨折内固定术后的分类编码。方法对某院2014年1月1日-2015年12月31日出院诊断为骨折内固定术后的342份病案进行回顾性分析,按照国际疾病分类原则,对骨折内固定术后进行编码。结果 342份诊断为骨折内固定术后的病案中,228份编码错误,错误率达66.67%,导致错误编码的主要因素是编码员和临床医师有效沟通不够。结论骨折内固定术后是不规范诊断名称,编码员在面对诊断骨折内固定术后时,要认真阅读分析病案,多与临床医师及同事进行沟通和讨论,按照国际疾病分类原则,提高编码水平。同时还应培训医师,促使其规范书写疾病诊断名称。
Objective To investigate the ICD-10 coding of fracture internal fixation after the operation by analyzing the main causes of hospitalized patients. Methods To conduct a retrospectively analysis on the 342 cases with discharge diagnosis for fracture internal fixation after the operation from January 1 st 2014 to 31 st 2015, then perform the ICD-10 coding of fracture internal fixation after the operation. Results Among the 342 cases which were diagnosed as fracture internal fixation after the operation, the coding of 228 cases is wrong, which accounted for 66.67%. The main factor of wrong coding is coder and physician. Conclusions The diagnosis of fracture internal fixation after the operation is nonstandard. Coders should read and analyse medical records carefully and communicate with clinical doctors while making coding of fracture internal fixation after the operation and raise the level of coding according to the encoding rules of the international classification of diseases. At the same time,physician should also be trained in order to write standard disease diagnosis.
出处
《中国病案》
2017年第10期40-42,共3页
Chinese Medical Record
关键词
骨折内固定术后
并发症
国际疾病分类编码
After the operation of fracture internal fixation
Complication
International Classification of diseases
