产后出血的主要诊断选择与编码

Main Diagnosis Choice and Coding of Postpartum Hemorrhage

目的通过对分娩伴产后出血病例的分析,明确分娩伴产后出血病例主要诊断的选择,以及准确编码。方法通过某院病案首页信息管理系统检索2012年-2016年产后出血病例,分析主要诊断选择情况以及编码情况,统计错误率。结果 2012年-2016年出院诊断中有产后出血的897例,其中诊断为产后大出血的228例,产后出血患者主要诊断选择错误率12.93%,其中以产后大出血为主要诊断病例占错误率的92.24%。结论以产后大出血为主要诊断病例应以导致产后出血的原因作为主要诊断,并应注意合并编码的使用。医务部门对临床医师的病案首页填报进行培训,编码人员加强与临床医师的充分沟通,共同确保编码的正确性,协同完成病案首页上报工作。

Objective Through the analysis of the cases of postpartum hemorrhage, the choice of the main diagnosis and accurate coding of the cases with postpartum hemorrhage were determined.Methods Through the front sheet of medical records information management system, we searched the cases of postpartum hemorrhage during 2012 and 2016, analyzed the main diagnosis and coding, and calculate error rate.Results There were 897 cases of postpartum hemorrhage, of which 228 cases were diagnosed as postpartum hemorrhage, the error rate of the main diagnosis was 12.93%, among which the postpartum hemorrhage was the main diagnostic case, accounting for 92.24% of the error rate.Conclusion The main diagnosis of massive postpartum hemorrhage cases should be the main cause of postpartum hemorrhage, and the use of combination coding should be paid attention to. The medical department conducts training on the front page of clinicians, and codes staff to strengthen communication with clinicians to ensure the correctness of coding and to complete the front page reporting.