5例产科相关病例编码分析  

Analysis on the Coding of Obstetric Related Medical Records

作　　者：黄娜萍 刘红[1] 郑嘉伟 刘俊[1] 邬小凤 方丹丹 徐倩 赵云龙 Huang Naping;Liu Hong;Zheng Jiawei;Liu Jun;Wu Xiaofeng;Fang Dandan;Xu Qian;Zhao Yunlong(The Sixth Affiliated Hospital of Sun Yat-sen University,Guangzhou 510000,Guangdong Province,China;不详)

机构地区：[1]中山大学附属第六医院,广东省广州市510000

出　　处：《中国病案》2020年第11期53-55,共3页Chinese Medical Record

摘　　要：在国际疾病分类ICD-10中产科系统编码复杂、难度较大、编码员在编码时常常误编,编码错误率较高。通过回顾某院病案质控中产科病案编码错误较多的几种编码类型,例如产前染色体异常筛查、宫内感染、梗阻性分娩等,列出疾病编码查询过程,探讨相关疾病编码规则,总结导致编码错误的原因主要为编码人员对产科疾病的概念掌握不够准确,对产科疾病的发生发展情况不够了解,专业知识不够牢固和过度依赖计算机编码库编码。为提高产科病案编码质量应加强编码员编码专业技能培养;加强编码员与产科医师之间的交流;制定疾病编码质控制度;设立专科编码员工作模式;适当增加编码员数量,确保编码员有足够的时间了解病案中疾病的发生发展过程,提高产科疾病编码的准确率。In the International Classification of Diseases ICD-10,obstetric system coding is complicated and difficult.Coders often make errors when coding,and the coding error rate is high.In this paper,by reviewing the codes with the most errors in obstetric medical records in the quality control of our medical records,we found existing problems and analyzed the causes of the problems to find ways to improve the quality of obstetric medical records.It was found that the lack of clinical knowledge of coders and the inadequate use of professional coding knowledge were the main reasons leading to poor coding quality.Coders should improve their coding expertise,expand their clinical knowledge,and follow up with the latest developments in the obstetrics department in a timely manner,and work closely with clinicians to ensure the accuracy of their coding.

关 键 词：产科 临床知识 案例分析 ICD-10编码 

分 类 号：R197.323[医药卫生—卫生事业管理]