葡萄膜炎ICD-10编码探讨  

Discussion of ICD-10 Coding on Uveitis

作　　者：牟怡平[1] 彭蓉[1] 王瑞涛[1] Mu Yiping;Peng Rong;Wang Ruitao(The First Affiliated Hospital of Xi’an Jiaotong University,Xi’an 710061,Shanxi Province,China)

机构地区：[1]西安交通大学第一附属医院,陕西省西安市710061

出　　处：《中国病案》2020年第6期18-21,共4页Chinese Medical Record

基　　金：西安交通大学科研基金软科学科研项目(2015YK36)。

摘　　要：目的通过分析葡萄膜炎编码现状及错误编码原因,探讨不同类型葡萄膜炎编码,提高编码准确率。方法收集某三级甲等医院2015年1月1日-2019年12月31日出院主要诊断为葡萄膜炎的病案资料164份,检查诊断书写和编码的准确性,统计错误编码率,并对错误编码类型进行分析。结果 164份住院病案首页中共有63例编码错误,占总葡萄膜炎病例的38.41%,错误编码类型包括:亚目分类错误、类目分类错误、未使用合并编码、漏编码、双重分类错误,不同类型葡萄膜炎错误编码类型不同。结论葡萄膜炎编码错误率较高,通过分析错误原因并提出对策,建立长效改进措施,以提高编码准确性。Objective To improve the coding accuracy of uveitis by analyzing the current situation of uveitis coding and the reasons of wrong coding.Methods 164 medical records with uveitis as the main diagnosis were collected,the accuracy of diagnosis writing and ICD-10 coding were checked,the error coding rate was counted,and the type of error coding was analyzed.Results There were 63 cases of coding errors,accounting for 38.41%of the total cases of uveitis.The types of coding errors included:sub classification errors,classification errors,unused combined coding,missing coding,double classification errors.Different types of uveitis had different types of coding errors.Conclusion Based on the current that high rate of uveitis coding errors,we have established long-term improvement measures by analyzing the causes of errors to improve coding accuracy.

关 键 词：葡萄膜炎 疾病编码 ICD-10 编码质控 

分 类 号：R197.323[医药卫生—卫生事业管理] R773.9[医药卫生—公共卫生与预防医学]