艾滋病ICD-10常见编码错误案例分析

Error Cases Analysis of AIDS ICD-10 Common Coding

目的调查艾滋病编码现状,对编码错误原因进行分析,旨在提高艾滋病编码的准确率。方法回顾性调查某院2015年收治的艾滋病病案713份,逐份对疾病编码进行审核分析,归纳出4种错误类型并进行百分比统计。结果 713份病案编码错误达76份,占10.7%。其中编码逻辑错误35份,占46.1%;合并编码错误24份,占31.6%;综合编码错误10份,占13.2%;选择编码错误7份,占9.2%。结论注意审核编码之间逻辑关系;艾滋病与并发症要合并编码,但编码HIV发生之前已存在的疾病时,该疾病要分开编码,且这个疾病应作为附加编码;主要诊断注意综合编码.7的运用;根据艾滋病分期概念正确选择对应编码,慎用B24。

Objective To investigate AIDS coding the status quo,analyze code error,and improve AIDS coding accuracy.Methods 713 cases of AIDS medical records in 2015 were taken retrospective investigation,analyze and review the disease coding,conclude four types of errors,and carry out the percentage statistics.Results There are 76 cases with errors,accounted for 10.7%.The coding logic errors 35 cases（46.1%）;Merge coding errors 24 cases（31.6%）;Comprehensive coding errors 10 cases（13.2%）;Choose the coding errors 7 cases,accounted for 9.2%.Conclusion Pay attention to the logical relationship between codes,AIDS and complications should be merge code,Coding diseases which have been in existence before the AIDS occurs,and the disease as additional coding;Pay attention to comprehensive coding.7 in primary diagnosis;According to concept of stages of AIDS correctly select the corresponding code.B24 should be used with caution.