急性心肌梗死ICD-10编码常见问题剖析及应对策略  

Common problems in ICD-10code of acute myocardial infarction

作　　者：韩雪英[1] 张红英[1] 任建玲[1] 刘汛汛[1] 方敏[1] 张芳[1] 

机构地区：[1]武警总医院质量管理科,北京100039

出　　处：《武警医学》2015年第5期466-468,472,共4页Medical Journal of the Chinese People's Armed Police Force

摘　　要：目的探讨急性心肌梗死(acute myocardial infarction,AMI)的国际疾病分类(international classification of diseases,ICD)编码不准确的问题,分析错误原因,制定对策。方法选取我院2013-11至2014-10住院患者出院主要诊断编码为I21.-的病历348份,从病案库房中将纸质病历调出,以人工方式对主要诊断为急性心肌梗死的病历进行逐份检查、核实。结果 348份出院主要诊断编码为I21.-的病历中,总编码错误率为33.91%。结论临床医师应学习ICD-10的有关内容,掌握疾病诊断的书写规范;编码工作人员应熟悉ICD-10的结构,不断提高编码技能水平和编码的准确性。Objective To investigate of acute myocardial infarction （ referred to as AMI） the problems of accuracyinICD-10 classification and coding, and analyzeits causes of error, and countermeasures.Methods 348 copies of medical records ofinpatients-from November 2013 to October 2014 in this hospital with discharge diagnosis code of I21.-,were consulted.Results In the 348 cop-ies of medical record with discharge main diagnosis coded as I21.-, the total code error rate was 33.91%.Conclusions The hospital leadership should invite experts to hold ICD-10 related lectures,so as clinicians have the opportunity to learn about the content of ICD-10, writestandard disease diagnosis, as complete and specific as possible.The coding staffshould find problems in the work hard,learn-basic knowledge of ICD-10,be familiar with ICD-10 structure, learn the relevant medical knowledge, carefully communicate with clini-cians, when necessary, to correct code, and constantly improve their coding skills.

关 键 词：急性心肌梗死 诊断 国际疾病分类 ICD-10编码 

分 类 号：R195.4[医药卫生—卫生统计学]