影响医院ICD编码准确性的因素及针对性处理措施探讨  

Factors Affecting the Accuracy of Hospital ICD Coding and Corresponding Treatment Measures

作　　者：李晴晴 LI Qingqing(Record Room,Fujian Medical University Union Hospital,Fuzhou Fujian 350000,China)

机构地区：[1]福建医科大学附属协和医院病案室,福建福州350000

出　　处：《中国卫生标准管理》2022年第13期141-144,共4页China Health Standard Management

摘　　要：目的基于ICD-10编码原理,对已出院病案首页疾病的诊断分类编码进行了分析和统计,分析了目前疾病诊断编码存在的主要问题并采取有力措施提高疾病编码的准确性。方法对福建医科大学附属协和医院2019年5月—2020年5月的2000份出院病案进行随机抽查,对每一份出院病案的疾病编码进行复核,并记录错误下编码出错的主要类型。结果在随机抽样的2000份出院患者病案中,核实出病案编码错误档案205份,错误率为10.25%。205份编码错误病案的分布,包括主要诊断编码错误构成比为12.19%,损伤、中毒外因填写错误和遗漏的错误占20.97%,对其他诊断的误编漏编和多编错误占42.92%。结论院方应该制定相关制度,严格规范相关医疗人员病历书写行为。编码人员应不断掌握ICD-10的专业知识和临床医学知识,增强责任感,医院管理层在必要时应该采取奖惩等积极措施,进而来提高疾病编码编写的准确性。Objective Based on the ICD-10 coding principle,the diagnosis classification code of diseases on the first page of discharged medical records is analyzed and counted,the main problems existing in the diagnosis code of diseases are analyzed,and effective measures are taken to improve the accuracy of the disease code.Methods A total of 2000 medical records of discharge from our hospital from May 2019 to May 2020 were randomly checked.The disease codes of each medical record were rechecked,and the main types of coding errors were recorded.Results Among the 2000 medical records of discharged patients randomly sampled,205 files with wrong coding of medical records were verified,with an error rate of 10.25%.The distribution of the 205 medical records with coding errors included 12.19%of the main diagnosis and coding errors,20.97%of errors in filling in and omissions due to injury and poisoning,and 42.92%of errors in other diagnoses.Conclusion The hospital should formulate the relevant system and strictly regulate the medical record writing behavior of related medical personnel.Coders should constantly master the professional knowledge and clinical medical knowledge of ICD-10,enhance their sense of responsibility,and hospital management should take positive measures such as rewards and punishments when necessary,so as to improve the accuracy of disease coding.

关 键 词：病案 疾病诊断 ICD编码 准确性 因素 措施 

分 类 号：G272[文化科学—档案学]