脊髓疾病编码易错原因及应对策略  

Causes of coding errors in spinal cord diseases and countermeasures

作　　者：刘丽[1] 王森[1] 胡丹[1] LIU Li;WANG Sen;HU Dan(YangZhi Rehabilitation Hospital Affiliated to Tongji University,Shanghai 201619,China)

机构地区：[1]同济大学附属养志康复医院,上海201619

出　　处：《现代医院》2022年第3期389-392,共4页Modern Hospitals

摘　　要：目的分析某医院康复医学科住院病案脊髓疾病编码错误的原因并提出改进方案。方法采取随机抽取2018年1月1日—2020年12月31日500份脊髓疾病住院病案进行回顾性分析,查找错误原因。结果临床医师疾病诊断错误率为19.2%,编码员的编码错误率为3.2%。结论错误原因包括临床医师诊断不规范,缺乏主要诊断选择原则等病案专业知识;编码员过度依赖疾病诊断直接在诊断库中查找编码,缺乏与临床医师有效沟通。只有临床医师、治疗师、编码员多团队多专业相互协作、不断学习,才能不断提升诊断的规范性和编码的正确率。Objective To analyze the causes of coding errors of spinal cord diseases in inpatient medical records of rehabilitation medicine department of a key rehabilitation hospital and to propose improvement measures.Methods 500 inpatients with spinal cord diseases from January 1,2018 to December 31,2020 were randomly selected and analyzed retrospectively to find the causes of errors.Results The diagnostic error rate was 19.2% for clinicians and 3.2% for coders.Conclusion The causes of errors included clinicians’unstandard diagnosis and unfamiliar coding rules.Coders rely too much on disease diagnosis to find codes directly in the diagnosis database and lack effective communication with clinicians.Only when clinicians,therapists and coders cooperate with each other and learn continuously,can the standardization of diagnosis and the correct rate of coding be improved continuously.

关 键 词：康复医学科 脊髓疾病 疾病编码 易错原因 应对策略 

分 类 号：R197.323.1[医药卫生—卫生事业管理]