小儿肾盂输尿管连接部狭窄的主要诊断选择缺陷分析与对策

Analysis on the Main Diagnosis Selection Defects of Pediatric Ureteropelvic Junction Stenosis Diseases and Relevant Countermeasures

目的探讨小儿肾盂输尿管连接部狭窄病例中主要诊断选择存在的问题及改进策略。方法收集北京市某三甲儿童医院2008年1月-2013年12月病理诊断为肾盂输尿管连接部狭窄的病案802份,对病案首页中医师和编码员主要诊断选择情况进行回顾性分析。结果小儿肾盂输尿管连接部狭窄根据病因、临床表现、病理检查其主要诊断的选择及疾病分类编码不相同,本组病例正确的主要诊断编码先天性肾盂输尿管连接部狭窄(Q62.1)464例,占57.9%;肾积水伴肾盂输尿管连接处狭窄(N13.0)338例,占42.1%。在先天性肾盂输尿管连接部狭窄病例中,医师主要诊断书写错误率高达100%,编码员主要诊断选择错误率高达76.7%。结论医师应当正确书写疾病诊断名称,掌握疾病分类编码知识,正确选择主要诊断。根据疾病分类原则,当查到病因时要按病因编码。编码员在日常工作中不但要掌握编码知识,还应仔细阅读病案,学习相关医学知识,做到编码准确,更好服务于医疗、教学及科研。

Objectives To investigate the problems existing in the main diagnosis selection of pediatric ureteropelvic junction stenosis diseases and relevant countermeasures. Methods To collect 802 medical records with the pathologic diagnosis of ureteropelvic junction stricture from January 2008 to December 2013 in a Grade A Tertiary Children＇ s Hospital in Beijing city, and a retrospective analysis was conducted on the selection situation of main diagnosis made by doctors as well as coders. Results The main diagnosis of ureteropelvic junction obstruction in children was different according to the etiology, clinical manifestation and pathological examination. There were 464 patients ,Mth the right diagnosis coding of congenital ureteropelvic junction stricture （Q62. 1） which accounting for 57.9%, hydronephrosis with ureteropelvic junction stricture in 338 cases （42. 1%）. In the congenital ureteropelvic junction stenosis cases, physician diagnosis writing error rate as high as 100%, while diagnosis selection error rate was as high as 76.7%. Conclusions Doctors should write disease diagnosis names correctly, master the knowledge of classification coding and make the correct choice of main diagnosis. According to the classification of disease classification principle, to perform the coding according to the etiology when find the causes. Coders should not only master the coding knowledge in daily work, but also read the medical records carefully, study relevant medical knowledge to manage accurate coding, so as to provide better service for medical treatment, teaching and scientific research.