脑梗死编码错误情况分析

Analysis of Coding Errors in Cerebral Infarction

目的分析某院神经内科主要诊断为脑梗死的病案编码情况,从而提高神经内科的编码质量。方法使用病案信息系统检索神经内科主要诊断编码(ICD-10)为脑梗死I63的病案2019年1月1日-2019年12月31日共2247份,利用图表形式,分析脑梗死I63.0-I63.9编码的使用情况。结果2019年2247份病例中错误编码共337份,占总数的15.0%;其中脑梗死责任血管错误共120份,占总数的5.3%;脑梗死病因分型错误共135份,占总数的6.0%;脑梗死责任血管和病因分型错误共82份,占总数的3.7%。结论脑梗死I63的临床诊断书写习惯与ICD-10编码名称不同,错误率高,编码员要熟练掌握脑梗死的分类轴心,了解脑梗死的责任血管和病因分型,以便更准确使用I63.0-I63.9,减少残余类目I63.9的使用。

Objectives To analyze the coding of cerebral infarction in a department of neurology,so as to improve the coding quality.Methods A total of 2,247 records of cerebral infarction 163 were retrieved from the primary diagnostic code(ICD-10)of neurlogy department from January 1 st,2019 to December 31 st,2019.The use of i63.0-163.9 code was analyzed by using the chart form Results In 2019,337 of the 2247 cases were wrongly coded,accountingfor 15.0%of the total.There were 120 vascul ar errors responsi bl e for cerebral i nfarcti on,accounting for 5.3%of the total.135 cases of cerebral infarction were caused by typological errors,accounting for 6.0%of the total.There were 82 vascular and etidogical classification errors in cerebral infarction,accounting for 3.7%of the total.Conclusions The writing habit of clinical diagnosis of cerebral infarction 163 was different from the ICD-10 code name,with a high error rate.Coders should master the classification axis of cerebral infarction,understand the responsible vessels and etiological classification of cerebral infarction,so as to more accurately use 163.0-163.9 and reduce the use of residual category 163.9.