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目的探讨宫内节育器诊断编码,提高医疗保健机构保健编码质量。方法检索某院自2012年5月到2015年4月间的出院诊断为宫内节育器的病案,对病案进行回顾性分析,依据ICD-10国际疾病编码分类原则,进行再编码。结果总计检索出1347份病案,其中,宫内节育器错误编码合计270例,错误率达20.04%。主要错误原因有临床医师诊断名称书写不规范、编码员没有联系病历前后记录进行编码、编码员对疾病编码分类掌握不足,编码不完全等。通过分析,对宫内节育器诊断有了进一步的认识,并给予匹配对应的ICD编码。结论加强病案首页疾病诊断与手术操作名称的完整、规范填写,编码员培养良好的阅读病案习惯、熟练掌握国际疾病分类方法、强化查阅疾病编码书籍的能力,才能提高编码准确性。
Objective To explore the diagnostic coding of IUD and improve the health coding quality of health care institutions. Methods A case of IUD diagnosed in a hospital from May 2012 to April 2015 was searched. The medical records were retrospectively analyzed and re-encoded according to ICD-10 International Classification of Diseases Code. Results A total of 1347 medical records were retrieved, of which 270 were intrauterine device error codes with an error rate of 20.04%. The main reason for the error is clinicians do not write the name of the diagnosis, the coder did not contact records before and after the record coding, codec classification of disease coding inadequate, incomplete coding. Through analysis, the IUD diagnosis has been further recognized, and given the corresponding matching ICD code. Conclusion Enhancing the accuracy of coding by strengthening the name of the disease diagnosis and operation on the first page of the medical record and completing the normative compilation, developing a good habit of reading medical records by the coder, mastering the international classification of diseases and strengthening the ability to access disease coded books.