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目的探讨我院以头盆不称为指征的剖宫产中,诊断及ICD-10编码的准确性。方法采用回顾性研究方法,对北京市门头沟区医院2002年1月至2012年1月以头盆不称为指征施行剖宫产术的576例患者的临床资料进行分析。结果 576例病例中有357例诊断正确,219例诊断错误,头盆不称诊断的正确率为62.0%,编码的准确率也为62.0%,医生诊断笼统写成头盆不称,编码员就编为头盆不称。结论医生正确诊断头盆不称是提高编码准确性的关键。
Objective To investigate the accuracy of diagnosis and ICD-10 coding in cesarean section in our hospital with cephalopelvic disproportion indications. Methods A retrospective study was conducted to analyze the clinical data of 576 patients who underwent cesarean section in Beijing Mentougou District Hospital from January 2002 to January 2012. Results Among the 576 cases, 357 cases were correctly diagnosed, 219 cases were diagnosed incorrectly, the correct rate was 62.0% and the accuracy rate of coding was 62.0%. The general diagnosis of the doctor was incomplete and the coder compiled Not for the first basin. Conclusion The correct diagnosis of the head basin doctor is not the key to improve the accuracy of the coding.