胎儿宫内窘迫的诊断和ICD-10编码

Diagnosis and ICD-10 coding of fetal distress

目的探讨胎儿宫内窘迫的诊断和如何正确编写ICD-10编码。方法回顾性分析我院2010年1月至2013年12月收治的157例胎儿宫内窘迫的患者的病例。结果医生在病案首页上诊断就写胎儿宫内窘迫,没有分型和写出急慢性,编码员在此编码上错误率非常高,有编码急性的,有编码慢性的,分型也编的很乱。结论医院应加强培训,让临床医生了解有关ICD-10编码,编码人员要多学习临床业务知识,仔细阅读病案,经常与临床医生沟通,提高编码的准确性。

Objective To discuss the diagnosis and accurate ICD-10 coding of fetal distress.Methods 157 patients of fetal distress were retrospectively analyzed from January 2010 to December 2013.Results The doctor diagnosed fetal distress.There is not typing and acute and chronic.The error rate was coded very high by coders some were coded acute,some were coded chronic,the typing was coded very messy.Conclusion The clinical doctor should be strengthened training by hospital,Let them understand related ICD-10 coding,the coder study hard Clinical knowledge,read medical record carefuly and often communicate with clinician,to improve accuracy of code.