慢性肾功能衰竭ICD-10编码质量调查分析

Analysis on Quality Investigation about Chronic Renal Failure ICD-10 Coding

目的通过调查我院慢性肾功能衰竭的ICD-10编码质量,提高我院ICD-10编码的准确性。方法根据慢性肾衰竭的临床分期,结合ICD-10编码规则,回顾性对我院2009年1月1日至2011年12月31日所有出院的慢性肾衰竭病例编码质量逐一调查分析。结果调查的慢性肾衰竭病例有495例,编码错误149例,误码率30.1%。错误编码原因由于出院诊断太笼统,编码人员对专科知识掌握不够,对慢性肾衰竭的临床分期不清楚,没有仔细查阅病案,只笼统地根据出院诊断编码,分类原则不熟练等原因。结论加强临床医师的国际疾病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。

Objective Through investigating ICD-10 coding quality of chronic renal failure, it aims at improving the accuracy of ICD-10 coding. Methods According to clinical stages of chronic renal failure with combing ICD-10 coding principles, this paper had a retrospective analysis on coding quality of chronic renal failure discharged from January 1, 2009 to December 31, 2011. Results There are 495 cases of chronic renal failure in investi- gation, in which 149 cases have coding error whose rate of error coding is 30.1%. The reasons of wrong coding include too general discharged diagno- sis, inadequate professional knowledge, unclear about dinical stages and unskilled about classification principles of the coding-staffs, just giving coding according to discharged diagnosis without carefully reading medical records. Conclusions In order to improve the accuracy of ICD-10 coding, this paper suggests strengthening the classification knowledge and diagnosis writing standard training for clinical doctors and improving professional knowledge lev- el and responsibility of coding-staffs.