【摘要】 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。更多还原

【Abstract】 Objective To further strengthen the standardization and scientization of the documentation of the discharge diagnosis in our hospital,and improve the accuracy of coding in our hospital by investigating the quality of coding glomerular diseases with ICD-10.Methods A retrospective study on the main diagnosis and classifications of all discharged patients with glomerular diseases from January 1,2003 to December 31,2008 in our hospital were carried out.Result We have surveyed 4071 main codes,among which 3260 error codes were found;the wrong code rate reaches as high as 80.1%,which dues to non-standard diagnosis,the coders’ insufficient knowledge,doubtfulness,and carelessness in checking the codes that have been done,and the lack of the principles and methods of disease classification.Conclusions It is necessary to strengthen the training of the clinicians’ classification and the documentation,and to improve the coders’ knowledge in classification and their sense of responsibility in coding.Consequently,the accuracy of coding with ICD-10 can be improved.更多还原