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目的了解出院诊断ICD-10编码的准确性,分析造成编码错误的原因,探讨提高ICD编码准确性的方法和对策。方法随机抽取2009年产科、肿瘤科、创伤科、传染科及儿科各1000份出院病案进行ICD-10编码的核查分析。结果 5000份病案中主要诊断选择错误的就有84份,错误率为1.6%;其他诊断编码错误的有1053个,错误率为5.7%。其中产科的ICD-10编码错误率最高为6.6%;肿瘤科6.2%;创伤科6.1%;传染科5.0%;儿科3.9%。结论医师准确、规范、完整书写出院诊断,病案编码员认真执行编码原则和仔细阅读病案内容,以确保编码的准确性。
Objective To understand the accuracy of ICD-10 coding for discharge diagnosis, analyze the causes of coding errors and discuss the ways to improve the ICD coding accuracy and countermeasures. Methods A total of 1000 discharged cases of obstetrics, oncology, traumatology, traumatology, pediatrics and pediatrics in 2009 were randomly selected for verification of ICD-10 coding. Results There were 84 major misdiagnoses in 5000 medical records, the error rate was 1.6%. There were 1053 other miscodes with error rates of 5.7%. Which obstetric ICD-10 coding error rate up to 6.6%; Oncology 6.2%; Traumatology 6.1%; Infectious Diseases 5.0%; Pediatric 3.9%. Conclusion The physician accurately, normatively and completely explained the diagnosis of discharge, and the medical record coder conscientiously implemented the coding principles and carefully read the contents of the medical records to ensure the accuracy of coding.