摘要
目的分析影响医院病案疾病诊断ICD编码准确性的因素,并提出相应的处理对策,提高医院ICD-10编码准确性。方法对本院2010年1月至2016年12月出现编码错误的368例患者资料进行回顾性分析,通过正规编码流程核对编码错误情况,分析引起编码错误原因。结果医师病历书写不规范引起编码错误比例最大,达51.90%,其次是编码员主导词选择错误及其专业水平及特殊疾病编码错误,分别占24.18%、14.67%、10.33%。结论临床医师和编码员仍是影响编码准确性的主体人员,为提高临床ICD-10编码准确性,除加强编码员对编码分类规则掌握程度外,加强编码员工作责任心、提高其专业素养、强化医师病历的规范书写均是提高编码准确性的有效途径。
Objective To analyze the factors affecting the accuracy of ICD coding in the diagnosis of hospital medical records,and to propose corresponding countermeasures to improve the accuracy of ICD-10 encoding in hospitals.Methods A retrospective analysis was performed on 368 patients with coding errors from January 2010 to December 2016 in this hospital.The coding error was checked through a formal coding process and the causes of coding errors were analyzed.Results The inconsistent writing of doctor's medical records caused the largest proportion of coding errors,which was 51.90%,followed by the errors in the selection of coder's leading words and their professional standards and coding errors of special diseases,accounting for 24.18%,14.67%,and 10.33%,respectively.Conclusion Clinicians and coders are still the main personnel who influence the accuracy of coding.In order to improve the accuracy of clinical ICD-10 coding,in addition to strengthening the coders'degree of mastery of coding classification rules,the work of coders should be strengthened and their professionalism enhanced.Strengthening the standard writing of physician's medical records is an effective way to improve the accuracy of coding.
作者
贾友波
宋宪锟
Jia Youbo;Song Xiankun(Department of Medical,Yanggu County People's Hospital,Liaocheng City,Shandong Province,Liaocheng,Shandong,252300,China;Liaocheng Second People's Hospital of Shandong Province,Liaocheng,Shandong,252600,China)
出处
《当代医学》
2020年第6期117-120,共4页
Contemporary Medicine
关键词
医院病案
疾病诊断
ICD-10
编码准确性
影响因素
处理对策
Hospital medical records
Disease diagnosis
ICD-10
Coding accuracy
Influencing factors
Treatment strategy
