摘要
目的了解中毒疾病分类编码不准确性的问题,分析错误原因,探讨对策。方法利用医院现有的病案首页管理信息系统,检索2010年-2013年中毒疾病分类编码,并与相关病案进行逐一核对,从而统计错误编码量,计算错误率。结果2010年-2013年共有中毒疾病分类编码619例,其中91个主要编码编错,错误率14.7%,201例附加编码存在错误,错误率32.4%。结论病案编码人员应严格把握疾病分类编码的质量关,定期抽查编目质量,建议增加编码信息质量控制程序,提高编码准确性。
Objective To acquire issues related to inaccurate coding in classifications of poisoning diseases,analyze the error reason and discuss the solutions.Methods To take advantage of the home pages information management system currently used in the hospital,search the classifications coding of poisoning diseases during 2010 and 2013,check related medical records one by one,count the amount of error coding and calculate error rate.Results There were 619 cases of poisoning diseases classifications coding from 2010 to 2013,in which 91 cases existing errors in principal coding,the error rate was 14.7%,201 cases existing errors in additional coding and the error rate was 32.4%.Conclusions The medical records coding staff should control the quality of diseases coding strictly,examine the quality of category in the system regularly and add quality control program of coding information,so as to improve the accuracy of coding.
出处
《中国病案》
2014年第7期34-36,共3页
Chinese Medical Record
关键词
中毒
国际疾病分类
分析
Poisoning
International Classification of Diseases
Analysis