507例原发性肾小球疾病编码质量分析  

Analysis of the Coding Quality of 507 Cases of Primary Glomerulopathy

作　　者：王晶晶[1] 赵慧智[1] 王卫卫[1] Wang Jingjing;Zhao Huizhi;Wang Weiwei(Hebei General Hospital,Shijiazhuang 050051,Hebei Province,China;不详)

机构地区：[1]河北省人民医院,河北省石家庄市050051

出　　处：《中国病案》2023年第9期15-17,共3页Chinese Medical Record

基　　金：河北省2019年度医学科学研究重点课题计划(20190212)。

摘　　要：目的分析某院原发性肾小球疾病的编码错误原因,提高原发性肾小球疾病编码准确率。方法检索某院肾内科2019年1月1日-2021年12月31日出院诊断为原发性肾小球疾病的病案共计507份,逐份核查疾病编码,统计错误率,总结编码经验。结果507份原发性肾小球疾病的病案中有37份编码错误,错误率占7.29%。原疾病编码中无N02.7及N04.5,原疾病编码为N02.1、N02.3、N04.0的例数均低于实际例数,N02.8、N04.1、N04.2、N04.3的例数均高于实际例数。其中将N02.1错编为N02.8或N02.3所占比例最高,占错误总数的64.86%。根据临床专科意见建立了常见原发性肾小球疾病不同病理分型与ICD-10的对应关系。结论原发性肾小球疾病分类较复杂,容易出现编码错误。编码员应熟练掌握编码原则,与临床科室沟通互动。临床医师应规范诊断书写行为,共同提高编码质量。Objectives This study aims to analyze the causes of coding errors in primary glomerulopathy in a hospital,so as to improve the coding accuracy of primary glomerulopathy.Methods A total of 507 medical records of primary glomerulopathy diagnosed in the Department of Nephrology of a hospital from January 1,2019 to December 31,2021 were retrieved.The disease codes were checked one by one,the error rate was counted,and the coding experience was summarized.Results Among the 507 cases of primary glomerulopathy,37 cases were incorrectly coded,with an error rate of 7.29%.There were no N02.7 and N04.5 in the original disease code.The numbers of cases with the original disease code N02.1,N02.3,and N04.0 were all lower than the actual cases,while the number of cases with the original disease code N02.8,N04.1,N04.2,and N04.3 were all higher than the actual cases.Among them,N02.1 was wrongly coded as N02.8 or N02.3,accounting for 64.86%of the total number of errors.According to the opinions of clinical specialists,the corresponding relationship between different pathological types of common primary glomerulopathy and ICD-10 was established.Conclusions The classification of primaryglomerulopathy is complex and prone to coding errors.To improve the coding quality of primary glomerulopathy,coders and clinicians need to cooperate with each other.Coders should master coding principles and interact with clinical departments.Clinicians should standardize diagnostic writing behavior and provide complete and accurate diagnostic information for medical record coding.

关 键 词：原发性肾小球疾病 ICD-10编码 质量控制 

分 类 号：R197.323[医药卫生—卫生事业管理]