200例血管炎ICD-10编码分析  

Coding Analysis of 200 Cases of Vasculitis

作　　者：张苑 赵雨辰 朱爱霞 程晓峰 孟娜 Zhang Yuan;Zhao Yuchen;Zhu Aixia;Chen Xiaofeng;Meng Na(Quality Management Office,Nanjing Drum Tower Hospital,Nanjing 210008,Jiangsu Province,China;不详)

机构地区：[1]南京鼓楼医院质量管理办公室,江苏省南京市210008

出　　处：《中国病案》2024年第10期42-45,共4页Chinese Medical Record

基　　金：南京大学中国医院改革发展研究院课题项目;南京鼓楼医院医学发展医疗救助基金会资助项目(NDYG2022088、NDYGN2023025)。

摘　　要：目的通过对血管炎编码进行质量监控并对缺陷原因进行分析,以提高血管炎编码正确率。方法选择某院2022年1月1日-2022年12月31日出院的主要诊断编码为血管炎的病案共200份。以2012年CHCC共识为标准对血管炎进行分类,并依据国际疾病分类ICD-10编码规则进行疾病编码的质量控制,分析缺陷发生的原因并制定改进措施。结果发现31份血管炎病案存在编码错误,占比15.5%,错误类型分为:类目错误12例,未使用星剑号编码11例,M31亚目错误8例,分别占血管炎病案6%、5.5%、4%。结论血管炎病案易发生错误编码,为提高编码正确率需要加强与临床医师沟通、提高编码人员专业技能、加强住院病案首页编码质控。Objectives Through the quality monitoring of the coding of vasculitis and the analysis of the defect causes,the accuracy of the coding of vasculitis was improved.Methods A total of 200 cases discharged from a hospital between January 1st,2022 and December 31st,2022 with a primary diagnosis coded as vasculitis on the first page were selected.The 2012 CHCC consensus was used as the standard to classify vasculitis,and quality control of disease coding was performed based on the International Classification of Diseases ICD-10 and coding rules to analyze the reasons for the occurrence of defects and develop improvement measures.Results Coding errors were found in 31 cases of vasculitis,accounting for 15.5%.The types of errors were divided into:category errors in 12 cases,non-use of star sword code in 11 cases and M31 subdivision errors in 8 cases,accounting for 6%,5.5%and 4%of vasculitis cases respectively.Conclusions Vasculitis cases were prone to errors in the selection of primary diagnosis codes,and in order to improve the rate of correct coding it was necessary to strengthen the communication with clinicians,improve the professional knowledge of coding staff,and strengthen the quality control of coding on the front page of the case.

关 键 词：血管炎 ICD-10 质控分析 编码错误类型 改进措施 

分 类 号：R593.2[医药卫生—内科学] R197.323[医药卫生—临床医学]