影响产科出血性疾病ICD-10编码准确性的原因分析  

Influencing Factors of the Accuracy of the Obstetrical Hemorrhagic Diseases ICD-10 Code

作　　者：黄杰雄[1] 吴东[1] 杨妹[1] 庞正钰 黄蓉[1] 钟思敏[1] 

机构地区：[1]湛江市妇幼保健院,广东湛江524038

出　　处：《黑龙江医学》2016年第8期765-766,共2页Heilongjiang Medical Journal

摘　　要：目的对影响产科出血性疾病ICD-10编码(第10次修订本《疾病和有关健康问题的国际统计分类》)准确性的原因进行研究分析,为医院管理、科研教学及社会利用提供真实有效的依据。方法从2010年6月始,对产科医护人员和病案管理编码员进行诊断与编码规范培训,制定专用质量监控记录表格,统一记录指标。结果诊断与编码规范培训干预前后编码缺陷率有明显差异,分别为16.64%和6.42%。结论临床医师应该严格按照"ICD-10"分类标准,认真填写病历的诊断,病案编码人员要根据病历诊断并结合病程记录,认真分析并核对,才能有效提高编码的准确性。Objective To research influencing factors of the accuracy of obstetric hemorrhagic diseases ICD- 10 code through analyzing the reasons,to find out the countermeasures to provide real and effective basis for hospital management,scientific research teaching and society. Methods From June,2010,diagnosis and coding standards training for obstetric nurses and medical record management was done,special quality monitoring record form was established,and record index was unified. Results Before and after diagnosis and coding standard training,coding defects have obvious difference,16. 64% and 6. 42%,respectively. The main reason is the medical writing defects. Conclusion Clinicians should fill medical diagnosis in accordance with the＂ICD- 10＂classification standard. Medical record coding personnel should do careful analysis and verification according to the medical diagnosis. This can effectively improve the accuracy of coding.

关 键 词：出血性疾病 编码 第10次修订本《疾病和有关健康问题的国际统计分类》 误用 

分 类 号：R197.3[医药卫生—卫生事业管理]