影响ICD编码准确性的因素及处理策略

Influence Factors and Countermeasures of the Accuracy of ICD Coding Huang

对影响医院病案中疾病诊断分类编码准确性因素进行分析,造成编码准确性的主要因素是医师的主要诊断选择不当,诊断名称填写不规范,编码人员专业素质不高,没有养成良好的工作习惯,以及当前我国缺少科学规范的疾病分类编码库。针对以上影响因素提出了加强对医师ICD相关知识的培训,建立ICD编码的质控制度和编码人员专业素质的培养等措施,以提高疾病诊断分类编码的准确性。

To analyze the influence factors of the coding accuracy of diseases diagnosis and classification in medical records of the hospital. We found many influential factors, such as lack of understanding to ICD knowledge among doctors, inappropriate main di- agnosis and unnormalized fill-out of diagnosis names. And factors involved in the coding staff were low professional quality, without well working habits, and the lack of a scientific and standardized diseases classification coding database in our nation also influenced the accuracy. Aimed at above influential factors, we should put these measures below into action to improve the accuracy of diseases diagnosis and classification, strengthen the training of ICD related knowledge among doctors , establish ICD coding quality control rules and attach importance to the cultivation of the professional quality among the coding staff.