某三甲医院国际疾病分类编码的质量分析

Quality Analysis on The International Classification of Disease in A Grade Three and First-Class Hospital

目的依照国际疾病分类ICD-10的编码原则对病案首页疾病诊断的编码进行质量分析,以提高编码的准确性。方法对近2011年-2012年出院的108363份病案进行随机抽样,得到病案4335份,对疾病编码进行逐一核查。结果 4335份病案中有261份存在编码错误,按病案份数计算的错误率为6.0%。结论编码人员应加强医学知识和国际疾病分类ICD-10相关知识的学习,不断拓宽广度与深度,增强其工作的责任心,提高疾病编码的准确性。

Objective To make a quality analysis on the disease coding in diagnosis of medical records home pages according to the encoding principle of ICD-10, so as to improve the accuracy of classification of diseases. Method A sample of 4335 cases randomly sampling from 108363 medical records between 2011 and 2012 in the hospital was obtained, and the disease coding of the sample were checked one by one. Remit 261 cases of medical records had mistakes and the error rate was 6.0%. Conclusion Coders should strengthen the study the clinical and professional knowledge of diseases as well as ICD-10 related knowledge, improve their coding skill, take high responsibility for working, so as to enhance the accuracy of classification of disease.