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目的分析肺结核病D86.0疾病分类编码使用情况,提高D86.0疾病分类编码准确率。方法根据《疾病和有关健康问题的国际统计分类第十次修订本》分类原则,检索某院存在D86.0疾病分类编码的病历。结果 D86.0疾病分类编码的正确使用取决于医师的正确诊断,医师易混淆肺结核病与肺结节灶;以及编码员缺乏临床专业知识,阅读病历不充分,与医生沟通不畅两方面因素。结论加强对临床医师正确填写病案首页出院诊断的培训,普及编码员的临床知识,提高编码员对D86.0疾病分类编码的认识,确保D86.0疾病分类编码的正确使用。
Objective To analyze the usage of coding and classification of tuberculosis D86.0 disease and to improve the accuracy of classification of diseases in D86.0. Methods Based on the principle of classification according to the “Tenth Revision of International Statistical Classification of Diseases and Related Health Problems”, the medical records of D86.0 disease classification codes in a hospital were searched. Results The correct use of the D86.0 code for disease classification depends on the correct diagnosis of the physician, the confusion of the physician with pulmonary tuberculosis and pulmonary nodules, the lack of clinical expertise of the coder, inadequate medical records, poor communication with the doctor. Conclusion The clinicians should be properly trained in the diagnosis of first-out hospital discharges, popularize the clinical knowledge of the coders, raise the coders’ awareness of the D86.0 disease classification codes, and ensure the proper use of the D86.0 disease classification codes.