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目的提高小儿腹泻病编码的准确率。方法采用医院病案管理系统检索某院2011年1月至2013年12月出院诊断为腹泻病的病案,对病案首页填写诊断腹泻病的编码情况进行回顾性调查分析。结果 3年小儿腹泻病占全部出院患者的5.44%,其中以婴儿发病住院最高,占61.27%,其次是幼儿,占17.27%。2011年和2012年小儿腹泻病编码错选归类于K52.9现象突出。阅读复习病案发现某院实际感染性腹泻占70.49%、非感染性腹泻占29.56%。结论小儿腹泻病编码准确率不高,医院要加强对临床医师的病案首页填写、ICD-10知识的培训,编码人员要加强与临床医师沟通,不断提高小儿腹泻病编码的准确性。
Objective To improve the accuracy of coding for pediatric diarrhea. Methods A hospital medical record management system was used to search the medical records of a hospital diagnosed as diarrhea from January 2011 to December 2013 and the retrospective investigation was made on the coding of the diagnosis diarrhea. Results Pediatric diarrhea accounted for 5.44% of all discharged patients in 3 years. Among them, the incidence of infants was the highest, accounting for 61.27%, followed by young children, accounting for 17.27%. The 2011 and 2012 pediatric diarrheal disease codes are misclassified as K52.9 highlighted. Read the review of medical records found that a hospital actual infectious diarrhea accounted for 70.49%, non-infectious diarrhea accounted for 29.56%. Conclusion The coding accuracy of pediatric diarrhea is not high. The hospital should strengthen the homepage of clinicians’ medical records and train the ICD-10 knowledge. The coders should strengthen the communication with clinicians and improve the accuracy of coding of pediatric diarrhea.