产科ICD-10疑难编码处理方法研究

Research of dealing with the difficult ICD-IO code of obstetrics

目的探讨产科ICD-10疑难编码的原因，提出解决的对策，从而提高ICD编码的准确性。方法收集我院2008--2011年产科出院病人病案首页中的疑难编码，并对其成因进行分析研究，提出处理方法和技巧。结果4年间共收集疑难编码3281例，由并发症复杂造成编码困难1210例，受产程、时间及母子关系影响的疑难编码1040例，临床医师书写诊断不规范造成编码困难的765例，临床诊断与ICD不一致的疑难编码90例，其他原因造成编码困难的176例。结论认真细致阅读病案，分析研究疑难编码的原因，了解疾病的病因、病理以及疾病发展，善于与临床医生沟通，掌握ICD．10疾病分类基本原则，采用科学的编码方法和技巧，是提高编码准确性的关键。

Objective To find out the reasons of the difficult ICD-10 codes of obstetrics and explore the solutions in order to improve accuracy of ICD coding. Methods Collecting the difficult ICD-10 codes of obstetrics from 2008 to 2011 and analyzing them one by one, then classifying them by the causes. Results We aggregately collected 3 281 difficult codes in obstetrics, 1 210 of them were caused by complex complication, 1 040 by influence of labor, time or relationship between mother and infant ,765 were written in non-standard way on diagnoses by the clinical doctors, 90 by the discrepancy between clinical diagnosis, and 176 by other causes. Conclusion Reading medical record seriously and carefully, analyzing reasons, understanding causes of disease, pathology, clinical characteristic, and communicating clinical doctor, holding the basic principles of ICD-10 operation classification, taking the scientific techniques to deal with the difficult codes are the key points to analyze thoroughly the causes of the difficult codes.