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目的提高编码员对产前诊断出生缺陷编码的准确率。方法从某出生缺陷预防控制研究所的病案统计管理系统中检索2015年1月1日-2015年12月31日病案首页编码中包含有O04伴O35/O36.2/O36.5和O35/O36.2/O36.5伴73.8 001(多胎妊娠减胎术)的病案,通过电子病案系统对检索出的每一份病案进行检查。结果 182份病案中,编码有误的共29份,编码错误率40.24﹪,其中,产前诊断胎儿染色体异常、胎儿遗传性疾病的编码错误率最高,超过50﹪,其他类型的胎儿畸形编码错误率在35%~47.4﹪。结论部分编码员对出生缺陷的概念不清楚,并且没有养成通读病案的习惯,还有临床知识匮乏,从而导致出生缺陷编码的错误率较高。
Objective To improve the accuracy of the coder in coding prenatal diagnosis of birth defects. Methods Retrieved from Medical Records Management System of a Institute for Birth Defect Prevention and Control From January 1, 2015 to December 31, 2015 The first page of medical records includes O04 with O35 / O36.2 / O36.5 and O35 / O36 .2 / O36.5 Cases with 73.8 001 (Multiple Pregnancy Ophthalmology) are examined for each medical record retrieved through the Electronic Medical Record System. Results Among the 182 cases, 29 cases were coded incorrectly and the coding error rate was 40.24%. Among them, the prenatal diagnosis of fetal chromosomal abnormalities had the highest coding error rate of fetal genetic diseases over 50%. Other types of fetal malformations were coded incorrectly Rate of 35% to 47.4%. Conclusion Some coders do not know the concept of birth defects and do not have the habit of read-through medical records and the lack of clinical knowledge, resulting in a higher error rate of birth defects coding.