出院诊断的填写对ICD-10编码准确性的影响

Influences of Discharge Diagnosis Fill In on the Accuracy of the ICD-10 Code

为了提高ICD-10的疾病编码准确性,分析了某院临床医师出院诊断填写有诊断书写随意化、诊断书写不详尽、相关诊断分解书写、术后诊断书写和肿瘤化疗科诊断书写不规范、主要诊断填写错误和出院诊断用英文书写等几项缺陷。由于以上缺陷导致了疾病分类编码错误,影响了病案检索查询和统计数据上报的准确性。准确的疾病编码首先来源于疾病诊断的正确书写,其次是编码员自身编码水平。要想提高疾病编码准确性,必须从临床医师和编码员两个方面进行改进。加强临床医师对ICD-10分类知识的了解及出院诊断书写培训,加强编码员专业素质、临床医学知识和阅读病案等各方面能力的培养,是提高ICD-10编码准确性的有效措施。

In order to improve the accuracy of ICD- 10 diseases code, we analyzed discharge diagnosis of the clinical physicians in a hospital and find several defects such as write at random, not detailed, relevant diagnostic separate written, postoperative diagnosis and diagnosis of cancer chemotherapy writing is not standard, The main diagnostic fill in error, discharge diagnosis written in English and so on. The above defects caused the coding errors,affecting medical record retrieval and the accuracy of the statistics report. Accurate disease coding from disease diagnosis correct writing first, followed by the coders coding level themselves. Strengthen the clinician knowledge of ICD- 10 classification and discharge diagnosis writing training, Strengthen coders＇ professional quality, clinical medical knowledge and reading ability are the effective measures to improve the accuracy of the ICD- 10 code.