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目的在国际疾病分类ICD-10的类目或亚目下,会有“包括”或“不包括”的辅助说明,如果在编码过程中不加以注意就会出现多编和错编等问题,分析问题的原因以提高编码员水平。方法利用病案管理系统进行检索,调出某院2014年出院诊断ICD-10编码中包含耳和鼻窦部的骨瘤、胆石症的胆囊及胆管梗阻、跖趾关节病理性脱位、肾输尿管结石伴肾盂积水伴泌尿系感染和下肢动脉粥样硬化性坏疽这五种疾病共244例,通过重新核对病案首页、出院记录等相关病案资料,统计这5种编码错误例数与其实际使用例数的比值,得到这五种疾病编码的错误率。结果通过对244份出院病案进行核查,共有133份“不包括”编码出现错误,合计错误率达到55%,其中耳和鼻窦部的骨瘤32例,错误编码27例,错误率为84%;胆石症的胆囊及胆管梗阻101例,错误编码24例,错误率为24%;跖趾关节病理性脱位70例,错误编码45例,错误率为64%;肾输尿管结石伴肾盂积水伴泌尿系感染32列,错误编码32例,错误率为100%;下肢动脉粥样硬化性坏疽9例,错误编码5例,错误率为56%。结论 “不包括”编码错误的原因主要是对ICD-10内容了解的不是很透彻,以及对医学知识欠缺,还需继续加强相关方面的知识以便提高编码的准确性。
Purpose There may be supplementary instructions for “including” or “not including” under the category or subheading of the International Classification of Diseases ICD-10, which may lead to multiple edits and errors if not paid attention to in the coding process Problems, analyze the reasons for the problem to improve the level of coders. Methods The medical records management system was used to search and retrieve the osteosarcoma of the ear and sinuses, including the gallbladder and biliary obstruction of the cholelithiasis, pathological dislocation of the metatarsophalangeal joint, renal pelvis and renal pelvis A total of 244 patients with hydrocephalus and urinary tract infection and lower extremity atherosclerotic gangrene were rechecked. The ratio of the five cases of coding errors to the actual cases , Get the error rate of these five diseases coding. Results A total of 244 cases of “not included” coding errors were found by checking 244 cases of discharge. The total error rate was 55%. There were 32 cases of osteoma of the ear and sinuses, 27 cases of error codes and an error rate of 84 %; Cholelithiasis gallbladder and bile duct obstruction in 101 cases, 24 cases of error coding, the error rate was 24%; metatarsophalangeal joint pathological dislocation in 70 cases, 45 cases of error coding, the error rate was 64%; renal ureteral calculi with hydronephrosis With urinary tract infection in 32, 32 cases of error coding, the error rate was 100%; lower extremity atherosclerotic gangrene in 9 cases, 5 cases of error coding, the error rate was 56%. Conclusion The reasons for the “not including” coding errors are mainly the lack of thorough understanding of the content of ICD-10 and the lack of medical knowledge. Knowledge on relevant aspects is also needed to be improved in order to improve the accuracy of coding.