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目的通过调查我院慢性肾功能衰竭的ICD-10编码质量,提高我院ICD-10编码的准确性。方法根据慢性肾衰竭的临床分期,结合ICD-10编码规则,回顾性对我院2009年1月1日至2011年12月31日所有出院的慢性肾衰竭病例编码质量逐一调查分析。结果调查的慢性肾衰竭病例有495例,编码错误149例,误码率30.1%。错误编码原因由于出院诊断太笼统,编码人员对专科知识掌握不够,对慢性肾衰竭的临床分期不清楚,没有仔细查阅病案,只笼统地根据出院诊断编码,分类原则不熟练等原因。结论加强临床医师的国际疾病分类知识及诊断书写标准培训,提高编码人员的专业知识水平及加强责任心,方能提高ICD-10编码的准确性。
Objective To investigate the ICD-10 coding quality of chronic renal failure in our hospital and improve the accuracy of ICD-10 coding in our hospital. Methods According to the clinical stage of chronic renal failure and ICD-10 coding rules, the quality of coding of all cases of chronic renal failure discharged from January 1, 2009 to December 31, 2011 in our hospital was retrospectively analyzed. Results A total of 495 cases of chronic renal failure were investigated, with a coding error of 149 cases and a bit error rate of 30.1%. Reason for error coding Discharge diagnosis is too general, the coder mastery of specialist knowledge is not enough, the clinical stage of chronic renal failure is not clear, did not carefully review the medical record, only based on the general diagnosis of the code of discharge, unscientific classification and other reasons. Conclusion It is possible to improve the accuracy of ICD-10 coding by strengthening clinicians’ training of international disease classification knowledge and diagnostic writing standards, enhancing the professional knowledge of coders and strengthening their sense of responsibility.