5000例病案编码错误原因分析  

An Analysis on Reasons of Wrong Coding for 5000 Cases of Medical Records

作　　者：李春兰[1] 陈新来[1] 

机构地区：[1]广东省惠州市第三人民医院,惠州市516002

出　　处：《中国病案》2011年第9期23-24,共2页Chinese Medical Record

摘　　要：目的了解出院诊断ICD-10编码的准确性,分析造成编码错误的原因,探讨提高ICD编码准确性的方法和对策。方法随机抽取2009年产科、肿瘤科、创伤科、传染科及儿科各1000份出院病案进行ICD-10编码的核查分析。结果 5000份病案中主要诊断选择错误的就有84份,错误率为1.6%;其他诊断编码错误的有1053个,错误率为5.7%。其中产科的ICD-10编码错误率最高为6.6%;肿瘤科6.2%;创伤科6.1%;传染科5.0%;儿科3.9%。结论医师准确、规范、完整书写出院诊断,病案编码员认真执行编码原则和仔细阅读病案内容,以确保编码的准确性。Objectives It needs to know about the accuracy of ICD-10 coding of hospitalization diagnosis and analyze the reasons causing wrong coding,exploring the methods and countermeasures of improving ICD coding accuracy.Methods We randomly selected respective 1000 hospitalization medical records from obstetrics,department of oncology,traumatic department,infection department and pediatrics for examination analysis of ICD-10 coding.Results There are 84 cases in 5000 medical records having wrong selecting of major diagnosis which error rate is 1.6%;there is 1053 wrong coding for other diagnosis which error rate is 5.7%.The error rate of ICD-10 coding of obstetrics is 6.6% that is the highest;department of oncology is 6.2%;traumatic department is 6.1%;infection department is 5.0%;pediatrics is 3.9%.Conclusions Correct,standard and complete hospitalization diagnosis by doctors and careful implement of coding principle and careful reading about medical record content are the guarantee of ensuring correct coding.

关 键 词：出院诊断 ICD-10编码 准确性 

分 类 号：R197.3[医药卫生—卫生事业管理]