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目的运用国际疾病分类ICD-10的编码原则,对住院病案首页疾病诊断分类编码进行统计调查分析,探寻改善分类编码现状的有效措施,进而提高分类编码的准确性。方法对某大型三甲医院2014年6月至2015年5月共16万余份住院病案按月随机抽样,共得到病案9852份,并对每份病案疾病分类编码进行审核,记录错误类型。结果 9852份病案中有1659份存在编码错误,错误比例为16.84%。结论掌握ICD-10编码知识和临床医学知识、增强编码员责任心、提升编码员工作待遇、医师规范书写病案,并制定编码相关的奖惩制度,是提高疾病分类编码准确性的有效措施。
Objective To apply the coding principle of International Classification of Diseases ICD-10 to conduct statistical investigation and analysis of the disease diagnosis classification codes on the first page of inpatient medical records, and to seek effective measures to improve the status quo of classification codes so as to improve the accuracy of classification coding. Methods A total of more than 160,000 inpatient medical records in a large A-class hospital from June 2014 to May 2015 were randomly sampled on a monthly basis. A total of 9852 medical records were obtained, and the disease classification codes of each medical record were reviewed and the types of errors recorded. Results There were 1659 encoding errors in 9852 medical records with error ratio of 16.84%. Conclusions Mastering the knowledge of ICD-10 coding and knowledge of clinical medicine, enhancing the sense of responsibility of coders, improving the working conditions of coders, standardizing medical record of physicians and formulating rewards and punishments related to coding are effective measures to improve the accuracy of coding of disease classification.