产科臀位分娩编码病例的回顾性分析  

Retrospective analysis of coded cases of obstetric breech delivery

作　　者：郑娅 徐敏慧[1] 金旎[1] 何国斌 吴丽娟 Zheng Ya;Xu Minhui;Jin Ni;He Guobin;Wu Lijuan(Jinhua Municipal Central Hospital,Jinhua 321000,China)

机构地区：[1]金华市中心医院,浙江金华321000

出　　处：《中国医院统计》2023年第6期461-463,468,共4页Chinese Journal of Hospital Statistics

基　　金：金华市中心医院中青年科研启动基金(JY2021-2-03)。

摘　　要：目的对某院产科臀位分娩相关疾病诊断ICD-10编码准确性进行分析,提高病案首页ICD编码质量。方法通过病案统计系统检索该院2016—2022年出院诊断ICD-10编码含O32.1、O64.1、O80.1或O83.1的所有臀位分娩病案,根据ICD-10疾病编码规则复核出院诊断的疾病编码,进行病案编码回顾性分析。结果695份病案中出院诊断编码错误的88份,错误率12.66%。结论为提高疾病编码的准确率,医院及科室应加强对疾病编码员的业务培训;编码员应加强专科业务知识的学习;在编码科室分工进行调整以后彼此之间要加强沟通,并且积极与临床科室交流沟通,努力提高医院病案首页编码准确率,更真实地还原每一份病案。Objective To analyze the accuracy of ICD-10 coding for the disease diagnosis associated with the breech delivery,so as to improve the quality of ICD coding on the first page of medical records.Methods All breech delivery medical records with ICD-10 codes of O32.1,O64.1,O80.1 or O83.1 in our hospital from 2016 to 2022,were retrieved through the medical records statistical system.The disease codes of patients diagnosed after discharge were reviewed according to ICD-10 disease coding rules,and the code of medical records was analyzed retrospectively.Results Out of 695 medical records,88 cases had the wrong discharge diagnosis codes,and the error rate was 12.66%.Conclusion In order to improve the accuracy of disease coding,hospitals and departments should strengthen professional training for disease coders.The coders should strengthen the learning of specialized professional knowledge.After the division of labor is adjusted in coding departments,it is necessary to strengthen communication with each other,and actively communicate with clinical departments,strive to improve the accuracy of the hospital′s medical record homepage coding,and restore each medical record more truthfully.

关 键 词：臀先露 ICD-10编码 分析 

分 类 号：R197.323[医药卫生—卫生事业管理]