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目的通过总结P07.0、P08.0、O03.903原编码存在的问题,提高编码员对出生体重和早产编码的准确率。方法从某医院病案统计管理系统检索出疾病诊断编码为P07.0、P08.0、O03.903的病例,再结合电子病例系统、相关文献等资料,对病例进行校正编码。结果出生体重在1000克~2499克之间,容易发生编码错误;部分孕晚期流产的病案,校正编码后编“早产”而非“流产”。结论出生体重的编码要注意查工具书,孕晚期流产的病案要注意查看其分娩结局,否则,很容易编码错误。
Objective To improve the accuracy of coders’ birth weight and preterm birth coding by summing up the existing problems of P07.0, P08.0 and O03.903. Methods The cases with disease diagnosis codes P07.0, P08.0 and O03.903 were retrieved from the medical records management system of a certain hospital, and the cases were corrected and encoded by combining the electronic case system and related documents. Results birth weight between 1000g ~ 2499g, prone to coding errors; part of the third trimester abortion medical records, corrected coding post “premature birth” rather than “abortion ”. Conclusion birth weight should pay attention to check the code of reference books, abortion late pregnancy should pay attention to see the delivery outcome, otherwise it is easy to encode errors.