摘要
通过调查肠炎疾病编码的使用情况,以寻求提高编码准确率的对策。对某院2016年以肠炎作为主要诊断的610份病案进行重新调阅并进行编码情况分析,发现病案编码错误13份。通过5个典型错误案例阐述归类出的5种错误类型,分别是编码员对疾病概念认识不清、基本功不扎实,编码原则未掌握、临床医师书写诊断不规范、编码员没有仔细阅读病例报告、部分初入行编码员对待工作不够严谨。总结改进措施,编码员除了提高自身编码水平外,还应对临床医师进行病案书写质量和基本的ICD编码知识培训,以应对按病种付费的逐渐应用,提高肠炎类疾病编码的准确性,做到一病一码,准确分类肠炎疾病。
Through investigating on 610 cases of a hospital's enteritis outpatients in 2016, to find out 13 caseswith coding mistake. To analyze mistakes on enteritis and colitis coding through 5 wrong cases, discuss its' causes which including coder is not clear about disease's concept; coder doesn't master coding rules; clinic doctors' diagnosis lack of standardization ; coder doesn't read case report carefully ~ some new coder are not cautious enough. This article advances some measures accordingly, we should improve the coding skill .level of coders and carry out the training to improve the clinics' patient record quality and to DRGs application and increase the accuracy of enteritis' enteritis and colitis correctively. basic ICD-IO coding knowledge, so that we can adapt coding, to be "One disease, One code" so classified
出处
《中国病案》
2018年第1期31-33,共3页
Chinese Medical Record
关键词
肠炎
疾病编码
ICD-10
Enteritis and colitis
Disease coding
ICD-10