139例全身性炎症反应综合征编码准确性分析

Analysis of Encoding Accuracy of 139 Cases of Systemic Inflammatory Response Syndrome( SIRS)

目的分析全身性炎症反应综合征(Systemic Inflammatory Response Syndrome,SIRS)编码错误的原因,以便提高SIRS编码的准确性。方法选取某医院2015年—2016年所有诊断为A40~A41编码范围的SIRS全部病案资料,查阅这些病案,按照ICD-10编码原则对应与SIRS相关的基本概念(菌血症、败血症、脓毒血症、毒血症)找出编码错误的原因并进行统计分析。结果 139份病案中所有与SIRS概念相关诊断编码错误的有35份,错误率为25.2%。导致错误编码的主要原因是对SIRS基本概念混淆不清,占42.9%;其次未查看血培养报告,占25.7%;选择编码欠精确,占17.1%;编码员未掌握相应的编码原则,占14.3%。编码员的医学基础知识掌握情况差别较大,个别编码员(属高年资,有医学背景)错误率高达51.4%。结论有针对性地加强编码员对急、危、重症医学基础知识的培训学习,熟练掌握SIRS选择编码的原则,强调编码员的工作责任心,可以提高编码的准确性。

Objective To analyze the causes of the errors in systemic inflammatory response syndrome （ SIRS） in or-der to improve the encoding accuracy of SIRS. Methods All cases diagnosed with SIRS in the encoding range of A40 - A41 from 2015 to 2016 in a hospital were selected and referred to. In accordance with the ICD - 10 encoding principle, these ca-ses were matched to the SIRS related basic concepts （bacteremia, septicemia, septicopyemia, toxemia） so as to find out the causes of encoding errors and make statistical analysis. Results In all 139 cases, there were 35 errors in the diagnosis of SIRS, with the error rate of 25. 2% . The main cause of encoding errors was confusion about the basic concepts of SIRS, ac-counting for 42. 9% ; the second cause was the blood culture report had not been read, accounting for 25. 7% ; then lack of precision when choosing encoding, accounting for 17. 1% ; the last was the coding clerks did not grasp the principles of enco-ding, accounting for 14. 3% . There was significant difference in the basic medical knowledge of coding clerks, and a few clerks with high seniority and medical background even had a error rate as high as 51. 4% . Conclusion In order to improve the encoding accuracy, targeted training for encoding clerks in medical basics of acute, critical and severe diseases should be promoted, principles of choosing SIRS encoding should be mastered and the sense of responsibility of encoding clerks should be emphasized.