易被错误分类到R00-R99的编码案例分析  

Case Analysis of Coding Easily Misclassified to R00-R99

作　　者：孔丹妹 孙鹏[1] Kong Danmei;Sun Peng(Beijing Tongren Hospital Affiliated to Capital Medical University,Beijing 100730,China;不详)

机构地区：[1]首都医科大学附属北京同仁医院,北京市100730

出　　处：《中国病案》2021年第10期41-42,共2页Chinese Medical Record

摘　　要：通过具体案例的分析总结ICD编码时恶病质、坏疽、休克、胸膜炎几种典型的疾病编码被错误分类到第十八章的情况。根据几个典型错误编码的病例,对照病程记录分析病例,分别找出错误编码到第十八章R编码的疾病的病因,并根据ICD-10的编码规则给出正确的编码。总结编码员易错误编码的原因,在于编码员专业知识欠缺,临床知识匮乏,忽略医师给出临床诊断的病因,或疾病具体分型,医师方面对病历书写的不重视,以及得出的改进办法为编码员提高业务能力,加强与临床医师的沟通,强化医师临床书写的规范。Through the analysis of specific cases,it is summarized that several typical disease codes of cachexia,gangrene,shock and pleurisy in ICD coding are misclassified to Chapter 18.According to several typical miscoded cases,the disease course records were compared to analyze the cases,to find out the causes of the diseases encoded in Chapter 18 R,respectively,and to give the correct coding according to the coding rules of ICD-10.It is concluded that the reason why the coders are prone to miscoding lies in the lack of professional knowledge,the lack of clinical knowledge,the neglect of the etiology of clinical diagnosis or the specific classification of diseases,and the fact that doctors do not pay attention to case writing.The improvement measures to improve the professional ability of the coders,strengthen the communication with clinicians,and strengthen the standardization of doctors’clinical writing.

关 键 词：ICD编码 第十八章 R编码 案例分析 不可归类在他处 

分 类 号：R197.323[医药卫生—卫生事业管理]