肌肉骨骼系统先天性畸形和变形疾病编码质量分析  

Coding Quality Analysis of Congenital Malformations and Deformations of the Musculoskeletal System

作　　者：部文茜[1] 王海军[1] 杨栩 郑奕 Bu Wenqian;Wang Haijun;Yang Xu;Zheng Yi(Department of Medical Records Management,The Second Hospital of Tangshan,Tangshan 063000,Hebei Province,China;不详)

机构地区：[1]唐山市第二医院病案管理科,河北省唐山市063000

出　　处：《中国病案》2025年第2期55-58,共4页Chinese Medical Record

摘　　要：目的分析肌肉骨骼系统先天性畸形和变形疾病编码存在的问题,并给出编码思路及改进建议。方法抽取2023年1月1日至2023年12月31日疾病编码为Q65-Q79的442份病案,2名编码员根据ICD-10编码规则及文献资料,筛选出疾病编码存在问题的病案,通过与临床医师讨论确认后汇总,对存在问题的编码进行分析。结果发现65份病案疾病编码存在问题,首先由于编码员业务水平差异造成的分类错误,包括字典库使用不规范25份(38.5%)、编码规则掌握错误19份(29.2%)和编码时未参考病史7例(10.8%);其次由于字典库存在的问题,包括查找结果与字典库不一致13份(20%)和字典库没有相应编码1例(1.5%)。结论肌肉骨骼系统先天性畸形和变形编码错误的主要原因是编码员未按编码规则查找编码,阅读病案不充分。编码员需要加强临床和编码知识的学习,对易错编码明确编码思路,绘制易于操作的表格,并加强对Q65-Q79编码监管,提高编码质量。Objectives To analyze problems in coding of congenital malformations and deformities of musculoskeletal system,and put forward coding ideas and suggestions for improvement.Methods From January 1st,2023 to December 31st,2023,442 medical records with disease codes Q65-Q79 were extracted.According to ICD-10 coding rules and literature data,two coders screened out medical records with disease codes with problems and summarized them into WPS forms after discussion and confirmation with clinicians,and analyzed the codes with problems.Results It was found that there were problems in the disease codes of 65 medical records.Firstly,there were classification errors caused by the difference in the professional level of coders,including 25 cases(38.5%)of irregular use of coding library,19 cases(29.2%)of incorrect grasp of coding rules,and 7 cases(10.8%)of no reference to medical history when coding.Secondly,due to the problems of coding inventory,including 13 cases of inconsistent search results with coding library(20%)and 1 case of no corresponding coding library(1.5%).Conclusions The main reason for coding errors of congenital malformations and deformities of musculoskeletal system was that coders did not look up codes according to coding rules,but over-rely on coding libraries and did not read medical records adequately.In view of the high error rate of this part,coders themselves should strengthen the study of clinical and coding knowledge,clarify coding ideas for error-prone coding,draw easy-to-operate tables,strengthen the supervision of Q65-Q79 coding,and conduct regular retrospective discussions in the department to improve coding quality.

关 键 词：先天性畸形 骨科 编码 

分 类 号：R68[医药卫生—骨科学]