基于计算机软件系统的疾病编码错误及纠错路径分析  

Analysis of errors in disease coding using computer software system and error correction paths

作　　者：姜珺 葛琳琳 张瑶 槐京阳 戴卉 Jiang Jun;Ge Linlin;Zhang Yao;Huai Jingyang;Dai Hui(Department of Statistics,the First Affiliated Hospital of Nanjing Medical University,Nanjing 210029,China)

机构地区：[1]南京医科大学第一附属医院统计科,江苏南京210029

出　　处：《中国医院统计》2022年第5期358-361,共4页Chinese Journal of Hospital Statistics

基　　金：江苏省医院协会医院管理创新专项研究课题(JSYGY-3-2021-PJ89)。

摘　　要：目的针对应用计算机软件系统进行疾病编码工作中时常出错的现象,透视编码错误的成因,提出改进路径,以提升疾病编码质量。方法结合工作实际,采用案例分析的方法,探讨应用计算机系统开展疾病编码出错的成因;进一步归纳分析,找到纠错路径。结果应用计算机进行疾病编码发生错误的原因主要包括两方面:一是编码人员过度依赖计算机系统,对ICD-10编码及疾病不够熟悉,简单套用电子编码库;二是计算机系统也存在优化的空间。结论编码员自身应不断加强学习医学知识,提高编码准确率;规模较大的医院可按临床科室对编码员进行分工,便于其对ICD的某些章节能够了如指掌,对相关疾病了解亦较为深入,以提高工作效率,减少错误;条件成熟时,可对计算机软件系统进行优化升级。Objective To aim at the frequent errors in disease coding using computer software systems,to analyze the causes of those coding errors,and to propose correction paths to improve the quality of disease coding.Methods Combined with practical work,the causes of errors in disease coding by computer software systems were discussed by case study.With further inductive analysis,paths to correct the errors were found out.Results There are two main reasons for the errors of disease coding by using computers.One is that coders,unfamiliar with ICD-10 codes and diseases,rely too much on the computer software system,and mechanically draw upon the electronic coding base.Second,there is also room for optimization in the computer software system.Conclusion Coders should keep learning medical knowledge and improve the coding accuracy.Large hospitals can divide the coding staff according to clinical departments,so that every coder can have a more specialized understanding of some chapters of ICD-10 and related diseases,so as to improve work efficiency and reduce errors.When the conditions are ripe,the computer software system can be upgraded.

关 键 词：疾病编码 ICD-10 计算机软件系统 纠错路径 

分 类 号：R197.323.1[医药卫生—卫生事业管理]