某院ICD-10疾病分类问题分析  

Analysis of ICD-10 Disease Classification in a Hospital

作　　者：吴妙婷[1] 许萍[1] Wu Miaoting;Xu Ping(The Fifth Affiliated Hospital of Sun Yat-sen University,Zhuhai 519000,Guangdong Province,China;不详)

机构地区：[1]中山大学附属第五医院,广东省珠海市519000

出　　处：《中国病案》2020年第8期40-42,共3页Chinese Medical Record

摘　　要：目的分析珠海市某院住院病案首页的ICD-10疾病分类错误问题,探讨编码错误率较高疾病的错误原因和改进方法。方法利用病案信息系统检索某院2018年-2019年的出院病案共161800份,按病案号由小到大排序,运用等距随机抽样筛选15%的病案作为研究对象,共计抽取病案24270份。审核编码与诊断是否符合,查阅病案相关内容核对是否有漏编码、不符合分类规则及分类不具体等情况,记录结果并进行统计分析。结果抽取的24270份病案中,发现疾病编码错误共231例,总错误率为0.95%。其中由于临床医师漏填诊断导致漏编码占51.1%,书写或录入编码错误占14.7%,不符合ICD编码规则占9%,没有细分具体的类型占13.4%,编码与临床诊断的疾病不对应占11.7%。编码错误率较高的疾病分别是应激性心肌病、巨结肠、手足综合征、甲状腺乳头状癌、终板炎。结论应加强培训医师规范、完整书写疾病诊断,完善编码质控机制,要求编码员熟练掌握ICD编码规则,不断学习积累相关疾病的医学知识,提高疾病编码的质量。Objective To analyze the errors of ICD-10 disease classification on the front page of medical records of a hospital in Zhuhai, and discusses the causes and improvement methods of diseases with high coding error rate. Methods The total of 161800 medical records were retrieved from a hospital in 2018-2019 by using the medical record information system. According to the order of medical record number from small to large, 15% of the medical records were selected as the research object by using the equal distance random sampling. A total of 24270 medical records were selected. Check whether the coding and diagnosis are consistent, check whether there is missing coding, non-compliance with classification rules and classification is not specific, and record the results and make statistical analysis.Results 231 out of 24270 cases were found wrong coding, the total error rate was 0.95%. Among them, 51.1% were missed coding due to doctor’s missed diagnosis, 14.7% were wrong coding, 9% did not conform to ICD coding rules, 13.4% did not subdivide specific types, and 11.7% did not correspond to diseases diagnosed clinically. The diseases with high coding error rate are stress cardiomyopathy, megacolon, hand foot syndrome, thyroid papillary carcinoma and endplate inflammation.Conclusion It is necessary to strengthen the training of doctors to standardize and complete the diagnosis of diseases, improve the coding quality control mechanism, require coders to master the coding rules of ICD, constantly learn and accumulate the medical knowledge of related diseases, and improve the quality of disease coding.

关 键 词：ICD-10 手足综合征 应激性心肌病 终板炎 

分 类 号：R197.323[医药卫生—卫生事业管理]