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目的正确认识不良生育史的临床意义,提高编码准确性。方法回顾性检索2016年第一季度首页具有“不良生育史”诊断的病案共793例,以编码完全正确、部分正确、完全不正确、诊断漏编码分析编码之准确性,统计方法为描述性统计。结果所有研究病例中,编码完全正确为548例,占69.10%;部分正确为93例,占11.73%;完全不正确为79例,占9.96%;完全漏编码为73例,占9.21%。结论通过培训加强临床医生对疾病分类知识的了解,同时编码人员要仔细阅读病历,加深对不良生育史诊断内涵的正确理解。规范临床诊断的填写,解决编码人员与临床医生对不良生育史理解的偏差,从而有效提高编码的正确性。
Objective To correctly understand the clinical significance of poor reproductive history and improve the accuracy of coding. Methods A retrospective search of the first quarter of 2016 with “unhealthy birth history,” the diagnosis of 793 cases of illness, to complete the correct code, part of the correct, completely incorrect diagnosis of leakage coding analysis of the accuracy of coding, statistical methods described Sex statistics. Results All cases were correctly coded with 548 cases (69.10%), 93 cases partially correct (11.73%), 79 cases totally incorrect (9.96%), and 73 cases completely missed (9.21%). Conclusions Through training, clinicians should enhance their understanding of disease classification knowledge, meanwhile, coders should carefully read the medical record and deepen the correct understanding of the connotation of the diagnosis of unhealthy birth history. To standardize the filling of clinical diagnosis, to solve the encoding staff and clinicians to understand the history of poor birth bias deviation, thus effectively improving the coding accuracy.