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目的提高编码员对ICD-10和ICD-9-CM-3编码的准确性。方法利用病案查询系统检索出某三甲医院2013年1月1日至2015年12月31日出院的2640份病案,其中“肾错构瘤”病案73份、“卵巢颗粒细胞瘤”病案34份、“胃肠道间质瘤”病案243份;“股静脉穿刺置管术的血液透析”病案742份、“血管内瘘吻合术的血液透析”病案909份、“VSD引流术”病案639份。所有病案以《中国病案》杂志“疾病与手术分类”专栏中曾公开发表的5篇论文中涉及的5种疾病和手术操作为检索词,对每份病案的编码进行回顾性研究。结果 2640份病案的疾病与手术操作编码错误共计2447例,错误率高达92.7%。其中,350份病案涉及到的3种疾病5个类型的疾病编码全不正确,编码错误率100%;2290份病案涉及到的3种手术操作编码错误均为漏编编码,错误例数2097例,编码错误率91.6%。结论《中国病案》杂志是中国病案专业唯一一份专业核心期刊,其中的“疾病与手术分类”专栏对编码人员的工作起到了积极性的指导作用,编码人员应该有效利用这份专业杂志,不断提高编码水平。
Objective To improve the accuracy of coders’ coding of ICD-10 and ICD-9-CM-3. Methods A total of 2640 cases of medical records discharged from a top-class hospital from January 1, 2013 to December 31, 2015 were retrieved by using the medical record inquiry system, among which 73 were diagnosed as renal malformations and malignant tumors, 34 cases of medical records, 243 cases of gastrointestinal stromal tumors, 742 cases of hemodialysis of femoral vein catheterization, 909 cases of hemodialysis of vascular fistula anastomosis, , “VSD drainage ” case 639 copies. All medical records were searched retrospectively on the basis of the five diseases and surgical operations involved in the five articles published in the column of “Chinese Medical Records” and “Diseases and Surgery Categories”. Results A total of 2,447 cases of disease and surgical operation coding errors were recorded in 2640 cases, with an error rate as high as 92.7%. Among them, 350 cases were involved in the three diseases five types of disease codes are not correct, coding error rate of 100%; 2290 cases involved in the three kinds of surgical coding errors are coding errors, the number of errors 2097 cases , Coding error rate of 91.6%. Conclusion China Medical Record Magazine is the only professional journals in Chinese medical record profession, in which the column of “Diseases and Surgical Categories” has played a positive role in guiding the work of coders. The coders should make effective use of this professional magazine , Continue to improve the coding level.