多发性骨髓瘤ICD-10编码质量分析  

Analysis of ICD-10 Coding Quality in Multiple Myeloma

作　　者：贾孙玉 丁丽萍[1] 邵洁白 李慧 朱婧[1] 梁世星 杨卉 彭也[3] Jia Sunyu;Ding Liping;Shao Jiebai;Li Hui;Zhu Jing;Liang Shixing;Yang Hui;Peng Ye(Department of Medical Record and Statistics,Zhejiang Provincial People’s Hospital,People’s Hospital of Hangzhou Medical College,Hangzhou 310014,Zhejiang Province,China;不详)

机构地区：[1]浙江省人民医院,杭州医学院附属人民医院,病案与统计科,浙江省杭州市310014 [2]国新健康保障服务集团股份有限公司,北京市100028 [3]浙江省人民医院,杭州医学院附属人民医院,血液科,浙江省杭州市310014

出　　处：《中国病案》2021年第7期33-36,共4页Chinese Medical Record

基　　金：2019年浙江省医药卫生科技计划项目(2019KY323)

摘　　要：目的调查某三甲综合医院多发性骨髓瘤疾病诊断编码情况,正确理解多发性骨髓瘤的复杂临床表现,分析编码错误原因,提升多发性骨髓瘤疾病诊断编码质量。方法通过医院病案信息系统检索2016年1月1日-2019年7月31日期间住院病案首页主要诊断或第一次诊断为多发性骨髓瘤,编码为C90的病案1397份,根据《疾病和有关健康问题的国际统计分类ICD-10》中的编码原则,回顾性核对疾病编码情况。结果1397份病案中,有98份存在疾病诊断编码错误,错误率达7.02%,其中编码错误条数共111条。总结错误类型主要有2类:第1类是主要编码错误,共99条,占比89.19%;第2类是形态学编码错误,共12条,占比10.81%。结论提高疾病诊断编码的质量,编码员不仅需要严格把握ICD-10编码规则,多翻阅编码字典,还应该仔细阅读病案,多积累临床知识。Objectives To analyze the diagnosis coding of multiple myeloma in a tertiary general hospital,correctly understand the complex clinical manifestations of multiple myeloma,and analyze the causes of errors,so as to improve the accuracy rate of disease diagnosis coding.Methods 1397 medical records with multiple myeloma(coded as C90)diagnosed on the front page of the inpatient medical record from January 1st,2016 to July 31st,2019 were retrieved through the hospital medical record information system.According to the coding principles in the International Statistical Classification of Health Problems ICD-10,retrospectively check the main diagnostic coding.Results Of the 1397 medical records,98 cases were miscoded,with the error rate of 7.02%,among which there were 111 coding errors.There were two types of coding error:the first type was 99 main diagnostic selection errors,accounting for 89.19%;The second type was 12 morphological coding errors,accounting for 10.81%.Conclusions To improve the coding quality of disease diagnosis,coders should not only strictly grasp the ICD-10 coding rules,read the coding dictionary,but also read the medical records carefully and accumulate more clinical knowledge.

关 键 词：多发性骨髓瘤 疾病诊断 ICD-10编码 质量 

分 类 号：R197.323[医药卫生—卫生事业管理]