【摘要】 目的通过对某院肛肠科常见病住院病案首页ICD编码错误原因分析,以提高肛肠科常见病编码的准确率。方法利用卫生统计系统检索2016年1月1日至2020年12月31日某院肛肠科主要诊断为痔、肛瘘、肛裂、肛周脓肿的病案,以疾病和有关健康问题的国际统计分类为标准,由资深编码员对住院病案首页编码进行质控,结果采用百分比计算错误率。结果病案总数2383份,编码错误530份,错误率为22.24%;其中肛瘘编码错误221例,占肛瘘编码总数的89.47%;肛裂编码错误303例,占肛裂编码总数的88.34%;痔编码错误6例,占痔编码总数的0.49%。结论肛肠科编码质量存在一些问题,以肛瘘的错误发生率最高。应加强编码工作的培训、指导、质控,提高编码正确率。更多还原

【Abstract】 Objective To improve the coding accuracy of common diseases in anorectal department by analyzing the coding errors caused by ICD on the first page of inpatient records in a hospital. Methods Use of health statistics system to retrieve the, a hospital anus bowel division main diagnosis of 2383 cases of discharged patients, anal fistula, anal fissure, hemorrhoids and crissum abscess of the medical record home page encoding information from January 1, 2016 to December 31, 2020, with the international statistical classification of diseases and related health problems(ICD-10) as the standard, by experienced coder to quality control of medical record home page, The error rate is calculated by percentage of the quality control results, and the proportion is summarized and analyzed. Results Among 2383 medical records from January 1, 2016 to December 31, 2020, there were 530 coding errors, with an error rate of 22.24%. Among them, 221 cases of anal fistula coding errors, accounting for 89.47% of the total number of anal fistula coding errors; 303 cases of anal fissure coding errors, accounting for 88.34% of the total number of anal fissure coding; Hemorrhoid coding error 6 cases, accounting for 0.49% of the total number of hemorrhoid coding. Conclusion There are some problems in the coding quality of anorectal department, and the error rate of anal fistula is the highest. Strengthen coding training, guidance, quality control, improve coding accuracy.更多还原