摘要
目的通过分析ICD-10中未特指编码的使用情况,寻找减少未特指编码误用的对策,提高编码准确率。方法总结ICD-10中所有未特指编码,对烟台某医院7230份病案的主要诊断重新进行编码,对未特指编码出现的情况进行统计汇总与分析。结果 7230份病案中有2134份病案(29.5%)应用了未特指编码,其中1059份(14.6%)病案属于错误使用。结论未特指编码在病案中的误用情况比较严重,编码员除了提高自身编码水平外,还应对临床医师进行简单的编码知识培训,规范诊断名称书写,并加强编码员与临床医师的互动与交流,以减少未特指编码的使用。
Objective To explorer the problems of misuse coding of unspecified in ICD-10,analyze its reasons and search for ways to improve the coding accuracy.Methods Summarizes all unspecified codes in the ICD - 10,recode the main diagnosis of the 7230 medical records,summarize and analyze the unspecified codes.Results There are 2134 unspecified coding,accounting for 29.5%; Among them,1059 unspecified coding misused,accounting for 14.6%.Conclusion It can be seen that the misuse of unspecified coding is serious.Coders in addition to improve the level of their own,also deal with coding knowledge training for clinicians,strengthen their communication.Through these ways,the misuse rate of unspecified coding will be reduced.
出处
《中国病案》
2014年第11期29-31,共3页
Chinese Medical Record
