ICD疑难编码研究与技术性处理  

An Investigation and Technical Management on ICD Knotty Coding

作　　者：梁耀[1] 陈祝萍[1] 王湛涛[1] 李东敏[1] 陈丽娟[1] 

机构地区：[1]广东医学院附属医院,湛江市524001

出　　处：《中国病案》2006年第1期29-31,共3页Chinese Medical Record

基　　金：湛江市科技攻关项目[2005-19]

摘　　要：目的收集研究ICD-10编码工作中的疑难编码,解决ICD分类无法编码及误码问题,减少误码率,提高ICD-10的分类水平。方法对收集于2004年1月1日至2005年9月1日的326例疑难编码进行原因分析。应用大量的临床专著及文献资料对疑难编码的疾病进行病因、病理、解剖、临床类型的分析研究,然后检索ICD-10分类专著及文献资料,应用灵活的分类技巧,最后确定编码。结果研究解决的编码分三种,“可确定编码”、“基本确定编码”、“拟定编码”。其中“可确定编码”213例,占65.3%；“基本确定”编码76例,占23.3%；“拟定编码”37例,占11.3%。结论全部疑难编码中由于临床诊断与ICD有差异引起的最多,其次是ICD-10未收录的疾病。因此,规范临床诊断,提高编码员的ICD分类技能,根据我国的情况补充ICD编码及索引,对解决疑难编码,提高ICD分类水平有积极的推动作用。Objective By collecting the knotty coding in ICD-10, we hope to solve the problem of failed coding and error coding on ICD sort, reduce the error coding rate, therefore, raise sorting level of ICD-10. Methods To analyze the causation of 326 pieces of knotty coding collecting from Jan. 1, 2004 to Sept, 1, 2005, and consult a great deal of clinic monograph and literature materiasl to investigate its pathogenesis, pathology, anatomy and clinical sort, then retrieve classify monograph and literature materials by ICD-10 skillfully, to certain suitable coding. Results： There are 3 kinds of coding for investigation： confirmed coding, confirmable coding and studying-out coding. And among them, the rate of confirmed coding is 65.3% （ 213 pieces of coding）, the rate of confirmable coding is 23.3% （76 pieces of coding） and studying-out coding is 11.3%（37 pieces of coding）. Conclusion The most of the knotty coding are caused by the difference between the clinical diagnosis and ICD coding, minority is some illness which isn＂ t embodied by ICD-10, Therefore, it is necessary to make the standard clinical diagnosis, to improve coders＇ ICD sort ability and to renew ICD coding and index in time according to the situation of our country. And it is good to solve knotty coding and raise ICD sort level.

关 键 词：ICD-10 疑难编码 分类 

分 类 号：R197.3[医药卫生—卫生事业管理]