不良生育史常见编码问题分析

Analysis on Common Coding Problems of Abnormal Childbearing History

目的正确认识不良生育史的临床意义,提高编码准确性。方法回顾性检索2016年第一季度首页具有"不良生育史"诊断的病案共793例,以编码完全正确、部分正确、完全不正确、诊断漏编码分析编码之准确性,统计方法为描述性统计。结果所有研究病例中,编码完全正确为548例,占69.10%;部分正确为93例,占11.73%;完全不正确为79例,占9.96%;完全漏编码为73例,占9.21%。结论通过培训加强临床医生对疾病分类知识的了解,同时编码人员要仔细阅读病历,加深对不良生育史诊断内涵的正确理解。规范临床诊断的填写,解决编码人员与临床医生对不良生育史理解的偏差,从而有效提高编码的正确性。

Objectives To realize the clinical meaning of abnormal children bearing history correctly, and improve the accuracy of coding. Methods In search of 793 cases of abnormal children bearing history diagnosis on the front pages during the first 3 months in 2016 retrospectively. Test the rate of accuracy of coding by totally accurate, partly accurate, inaccurate and omitted coding classification. The statistical method was descriptive analysis. Results In all selected cases, totally correct coding were 548 cases, partly correct were 93 cases,completely .incorrect were 79 cases, omitted coding were 73 cases. Conclusions The clinical doctors should realize the diseases classification through training, meanwhile, coders should read medical records carefully in order to strengthen understandings of abnormal childbearing history. The clinical doctors should standardize the writing diagnosis to solve the deviation between doctors and coders, so as to improve coding accuracy effectively.