产科疾病ICD-10编码质量调查分析及建议  

The Suggestion and Analysis of the Quality of Coding of Obstetrics by ICD-10

作　　者：陈祝萍[1] 梁耀[1] 陈丽娟[1] 

机构地区：[1]广东医学院附属医院信息科

出　　处：《中国病案》2005年第10期37-39,共3页Chinese Medical Record

摘　　要：目的通过调查我院产科疾病ICD-10编码质量,更好地促进出院诊断书写规范化、科学化以及提高分类编码准确性。方法回顾性对我院2003年1月至2004年12月2339份产科出院病案的出院诊断及其分类编码进行核查。结果调查主要编码2339个,次要编码1580个,错误编码358个,错码率9.1%。误码多由于出院诊断书写不规范,编码员对专科知识掌握不够、不按照先了解病情后编码,分类原则及方法不熟练等原因。结论加强医生分类知识及诊断书写的培训,提高编码员专业知识水平及加强其责任心,才能提高ICD-10分类准确性。Objective By analyzing the quality of coding by ICD-10 on obstetric disease in our hospital, to make the scientific and standardized documentation of the medical record and improve the quality of classification and coding. Methods We reviewed 2339 medical records in our hospital from January 1, 2003 and December 30th, 2004, and the discharged diagnosis and the codes of the sample were carefully checked. Results We analyzed 2339 primary codes and 1580 secondary codes, among them, 358 are wrong codes. The error rate was 9.1%. They are caused by non-standardized diagnosis for discharge, and wrong coding, as was caused by the coders is lack of professional knowledge, and they are not familiar with the principle and method of coding, or didn＇t follow the principle that the Coder should understand the patient＇s condition before coding. Conclusion Training the doctors in writing diagnosis should be strengthened and the coders should improve their professional knowledge and strengthen their responsibility.

关 键 词：产科 国际疾病分类(ICD-10) 质量 分析 ICD-10编码 产科疾病 质量调查 出院诊断 专业知识水平 分类编码 

分 类 号：R197.3[医药卫生—卫生事业管理]