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目的通过调查我院肾小球疾病的ICD-10编码质量,进一步加强我院病案出院诊断书写的规范化和科学化,提高我院ICD-10编码的准确性。方法回顾性对我院2003年1月1日至2008年12月31日所有出院的肾小球疾病病案的主要诊断及其分类编码进行核查。结果调查主要编码4071个,错误编码3260个,错码率高达80.1%,错误编码原因多由于出院诊断书写不规范,太笼统,编码人员对专科知识掌握不够,没有先仔细查阅病案后编码,分类原则及方法不熟练等原因。结论加强临床医师的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 By investigating the coding quality of ICD-10 glomerular disease in our hospital, we further standardize and scientifically standard the diagnosis and discharge of medical records in our hospital and improve the accuracy of ICD-10 encoding in our hospital. Methods The main diagnosis and classification codes of all discharged cases of glomerular disease in our hospital from January 1, 2003 to December 31, 2008 were retrospectively reviewed. Results There were 4071 major codes, 3260 wrong codes and 80.1% wrong codes. The reasons for wrong coding were as follows: the writing of diagnosis was too general and the coding staff had not enough knowledge of specialties; Principles and methods are not skilled and other reasons. Conclusion It is possible to improve the accuracy of ICD-10 coding by enhancing clinicians’ classification knowledge and standard writing of diagnostic writing, enhancing the professional knowledge of coders and strengthening their sense of responsibility.