767例以R编码作为主要诊断的错误原因分析

Error Reason Analysis of 767 Cases of R Encoding Main Diagnosis

目的:掌握R编码规则,提高主要诊断的正确性和疾病编码的准确率。方法:以国际疾病分类ICD-10(R00-99)为标准,采用病案管理系统检索某儿童医院2014年以R编码为出院主要诊断的1 270例病案,并对照病案记录资料进行回顾性统计分析。结果:以R编码为主要诊断的病案有1 270例,占出院病案总数的2.50%,阅读病案发现存在主要诊断疾病名称书写不规范、主要诊断和疾病编码选择错误共有767例,占60.39%。结论:临床医师对国际疾病分类编码知识和主要诊断选择原则不熟悉,编码人员业务素质和工作责任心有待加强。

Objective： To master R encoding rules, improve the accuracy of the main diagnosis and disease encoding. Methods： The ICD-10（R00-99 Encoding）was used as the standard, the medical record management system was applied to retrieve the 1 270 documents of a children＇s hospital in 2014, and the data were retrospectively analyzed. Results： There were 1 270 cases diagnosed by R encoding, which accounted for 2.50% of the total number of hospital discharge records, and 767 cases were found to be incorrect on the main diagnostic disease name, main diagnosis and the disease encoding selection. Conclusion： Clinicians are not familiar with the knowledge of the international classification of disease and the principle of the main diagnostic encoding choice, the quality of personnel and job responsibility of encoding should be strengthened.