【摘要】 目的 建立疾病和手术操作ICD编码智能管理系统以解决目前医院ICD编码管理的难点，降低信息上传错误率，提升编码准确率。方法 建立以国家临床版ICD编码为系统主索引的ICD编码智能管理系统，构建主索引编码与医保版ICD编码、院内版ICD编码之间的映射关系，实现实时维护和调整。并根据国家公立医院绩效考核、医院等级评审等要求，实现考核指标的ICD编码“标签”功能并建立知识库，嵌入住院医师工作站，便于实现对临床医生的智能提示和后期数据统计。结果 系统建立后，疾病诊断和手术操作名称编码等诊疗信息映射上传错误率明显下降(1.2‰vs 0.3‰,P<0.05);出院主要诊断和手术操作编码准确率明显上升(82%vs 91%,P<0.05; 78%vs 88%,P<0.05);临床医生和编码员满意率明显升高(65%vs 82%,P<0.05; 79%vs 88%,P<0.05)。结论 实践证明该系统能降低疾病诊断和手术操作ICD编码等诊疗信息映射上传错误率，提升编码准确性和完整性，提高ICD编码管理水平，促进医疗高质量发展。更多还原

【Abstract】 Objective To establish an intelligent ICD coding management system to solve the current difficulties in hospital ICD coding management, reduce the error rate of information uploading, and improve the accuracy of coding. Methods An ICD coding management system was constructed, with the national clinical version of ICD coding as the main index system. The mapping relationship between the main index coding and the medical insurance version of ICD coding, as well as the hospital version of ICD coding, was established to achieve real-time maintenance and adjustment. In accordance with the requirements of national public hospital performance evaluation and hospital level assessment, we will establish the ICD coding “label” function and knowledge base for evaluation indicators, embed them into electronic medical record system(EMR), and implement intelligent prompting functions for clinicians to facilitate systematic statistical analysis of data. Results After the establishment of the system, the error rate of mapping and uploading information such as disease diagnosis and procedures coding decreased significantly(1.2‰ vs 0.3‰, P<0.05). The accuracy of the main discharge diagnosis and procedures coding has significantly improved(82% vs 91%, P<0.05; 78% vs 88%, P<0.05). The satisfaction of clinicians and coders increased significantly(65% vs 82%, P<0.05; 79% vs 88%, P<0.05). Conclusion This system can reduce the error rate of mapping and uploading information, improve the accuracy and completeness of coding, enhance the management level of ICD coding, and promote the high-quality development of medical care.更多还原