【摘要】 目的 对静脉血栓栓塞症编码进行质量监控，分析常见缺陷，以期提高编码正确率。方法 选取某院2016年1月1日-2019年12月31日期间，出院诊断的主要诊断及其它诊断ICD-10编码：⑴下肢深静脉(静脉)血栓形成(I80.1～I80.3)；⑵肺栓塞(I26)：除外非血栓性肺栓塞，仅指肺血栓栓塞症，共检出3166份病案，其中下肢深静脉(静脉)血栓形成共2694例；肺栓塞共472例。由临床主治医师及编码员依据国际疾病分类ICD-10及编码规则进行疾病编码的质量控制，分缺陷发生原因制订改进措施。结果 289份下肢深静脉(静脉)血栓形成错误编码，占比最高达10.73%，错误原因归类为：遗漏编码占4.94%；主要诊断选择错误2.86%；编码亚目分类错误2.04%；合并编码错误0.89%。46份肺栓塞错误编码,占比共计9.75%，归类错误原因为：合并编码错误占比最高，达5.30%；主要诊断选择错误3.81%；遗漏编码0.64%。结论 影响编码正确率的有效措施包括提高编码员专业素质，编码时按步骤查找核对编码并阅读分析病案资料，定期规范化培训临床医师的病历书写，加强住院病案首页专项质控，统一使用疾病分类代码库，提高编码员与出院病例数的比例。更多还原

【Abstract】 Objectives The quality of venous thromboembolism coding was monitored and the common defects were analyzed to improve the coding accuracy. Methods The ICD-10 code of discharge diagnosis(main diagnosis + other diagnosis) of a hospital from January 1st, 2016 to December 31st, 2019:(1) deep vein(vein) thrombosis of lower limbs(i80.1-i80.3);(2) Pulmonary embolism(i26): excluding non thrombotic pulmonary embolism, it only refers to pulmonary thromboembolism. A total of 3166 cases were detected, including 2694 cases of deep vein(vein)thrombosis of lower limbs. There were 472 cases of pulmonary embolism. The clinical attending physician and coder shall conduct retrospective verification and analysis of disease coding according to ICD-10 and coding rules, and formulate improvement measures. Results 289 wrong codes of lower extremity deep vein thrombosis(DVT),accounting for 10.73%, were classified as: missing codes(4.94%), main diagnostic selection errors(2.86%),coding sub category errors(2.04%), combined coding errors(0.89%), of which missing codes were the main error causes of lower extremity deep vein thrombosis(DVT). 46 wrong codes of pulmonary embolism, accounting for 9.74%in total. The causes of classification errors are: combined coding error(5.30%), main diagnostic selection error(3.81%), missing coding(0.63%), of which combined coding error is the main error cause of pulmonary embolism.Conclusions Coding accuracy effective measures including to improve the coder specialized quality, coding according to the steps when the analysis of the medical record data, check the code and read regularly standardized training of clinical physicians, medical record writing, strengthen the hospital medical record front page special quality, uniform classification of diseases code base, improve coders and discharge in proportion to the number of cases.更多还原