【摘要】 目的回顾性调查我院编码为O00-O08出院病案的疾病和操作编码质量。方法运用病案统计系统综合查询功能,检索得到2013年编码为O00-O08出院病案,随机抽取500份逐份核查。结果错误编码210份,误码率42%,其中操作栏"双侧输卵管结扎术",应为66.32,结果 60例全部错误编码为66.39,误码率为100%,清宫术69.52共56例有40例编成69.02,误码率为71.4%,而疾病编码中因未正确使用共用亚目的误码率达96.15%,其次为异位妊娠分类轴心未体现、葡萄胎形态码未正确使用、忽略O00-O08类目不包括内容、及主要诊断与主要操作选择错误等。结论病案编码人员应有高度的责任感和质量意识,加强ICD-10及ICD-9-CM-3编码专业知识的学习与运用,要养成查阅病案相关记录和辅助检查的习惯,必要时与临床医生沟通,力求准确编码,提高病案管理水平。更多还原

【Abstract】 Objective To conduct a retrospective investigation on the coding quality of diseases and operations coded as 000 to 008 in the discharged medical records of our hospital.Methods To obtain the discharged medical records coded as 000 to 008 in 2013 with the application of comprehensive inquiry function of the medical records statistic system, then select 500 cases randomly for examination.Results There were 210 cases exiting mistake coding, the error rate was 42%, in which the coding of "bilateral tubal ligation" in the operation column should be 66.32 but was coded as 66.39 in all the 60 cases, the error rate was 100%.There were 56 cases of complete curettage of uterine cavity coded as 69.52 while 40 cases were coded as 69.02, and the error rate was 71.4%.The error rate caused by wrongly used common subitems in the diseases coding was 96.15%, others included the classify axis was not found in ectopic gestation, incorrect usage of hydatidiform mole coding, ignorance of content that not included in items coded from 000 to 008, as well as the mistakes in the choice of principal diagnosis and operations.Conclusions The coding staff should have highly developed sense of responsibility and quality awareness, strengthen the learning and application of ICD-10 and ICD-9-CM-3 professional coding knowledge, cultivate the good habits of reading related records with medical records and assistant examination, and communicate with clinical doctors if necessary, so as to get accuracy coding and improve the management level of medical records.更多还原