某三甲儿童医院新生儿室管膜下出血的编码情况分析  

Coding Analysis of Neonatal Subependymal Hemorrhage in a Certain Third Class A Children's Hospital

作　　者：刘颖[1] 曾跃萍[1] 宋菲 张欣[1] 陈燕华[1] 闫东丽 Liu Ying;Zeng Yueping;Song Fei;Zhang Xin;Chen Yanhua;Yan Dongli

机构地区：[1]首都医科大学附属北京儿童医院,北京市100045

出　　处：《中国病案》2018年第6期10-13,共4页Chinese Medical Record

摘　　要：目的通过分析某三甲儿童专科医院新生儿室管膜下出血的编码情况,规范编码分类。方法回顾性分析2014年1月1日-2017年12月31日的住院病案,选择病案首页疾病诊断为室管膜下出血的2704份病案为研究对象,编码情况进行分析。结果新生儿室管膜下出血的编码正确率为85.34%,错误编码中,编码员直接根据病案首页管理系统字典库的名称错误编码为新生儿脑室内出血和新生儿颅内出血的比例最高,分别占53.97%和16.56%。结论编码员要熟练掌握ICD编码原则,了解临床知识和解剖结构,有利于保障病案首页信息填写的正确性。Objectives In this study,we evaluate the coding situation of neonatal subependymal hemorrhage in a child＇s hospital to improve the accuracy of the coding quality of that disease.Methods Retrospectively consulted medical records of inpatients who attended this children＇s hospital from Jan.1,2014 to Dec.31,2017.A total of 2704 inpatients＇ medical records were included in this study.Results The accuracy rate of subependymal hemorrhage was85.34%.In error coding,the proportion of neonatal intracerebroventricular hemorrhage and neonatal intracranial hemorrhage was the highest,accounting for 53.97% and 16.5656%,respectively,according to the name of the dictionary of the first page of the medical record management system.Conclusion The encoder should master the principle of ICD coding and understand the clinical anatomical structure so as to ensure the correctness of the first page information of the medical record.

关 键 词：新生儿室管膜下出血 疾病编码 ICD-10 儿童医院 

分 类 号：R743.34[医药卫生—神经病学与精神病学]