疾病编码的缺陷分析及对策  

Defects Analysis on the Diseases Coding of a Hospital and Relevant Countermeasures

作　　者：马凤琴[1] 

机构地区：[1]北京市大兴区人民医院病案室,北京市102600

出　　处：《中国病案》2015年第11期26-28,共3页Chinese Medical Record

摘　　要：目的分析住院病案首页出院诊断编码的常见错误,以提高编码的准确性。方法随机抽取2014年病案,进行疾病编码检查,分析错误原因。结果 500份病案共有出院诊断2825条,检查出出院诊断和编码错误共791条,错误率为28%。其中漏编码的错误比例最大,占错误率的50.06%,漏编的最主要原因是由于编码员没有详细的阅读病案。结论加强编码员阅读病案的能力、熟练掌握ICD-10编码原则、熟悉ICD-10电子字典库的内容及提高临床知识水平、增强编码员责任心、并制定奖惩措施是提高编码准确性的有效措施。Objective＇To analyze the common mistakes o（ discharged diagnosis coding existing in the home pages, so as to improve the accuracy of the coding. Methods 500 cases of medical records in 2014 were selected randomly, then conducted an examination on the diseases coding and analyze relevant reasons. Results There were totally 2825 discharged diagnosis in the 500 cases of medical records, which accounted for 50. 06%, and the most important reason was the coder had not read the medical records carefully. Conclusions In order to improve the coding accuracy of the coders, we should take measures such as strengthen their ability of reading medical records, master the ICD-10 coding ruXes, get familiar with the content of the electric dictionary, improve their clinical knowledge, strengthen their responsibility as well as formulate some rules for rewards and punishment.

关 键 词：出院诊断 编码 准确性 

分 类 号：R197.323[医药卫生—卫生事业管理]