术后诊断的ICD-10编码情况

The Coding Situation of Postoperative Diagnosis in ICD-10

目的探讨术后诊断的疾病分类规则,以提高术后诊断编码的准确性。方法采用回顾性分析方法,检索某院2015年-2017年出院主要诊断符合"术后"诊断的病案,依据国际疾病分类原则进行再编码。结果总计3695份病案,其中术后诊断编码错误308例,错误率为8.34%。编码错误原因主要有临床医师诊断名称书写不规范、不完整,主要诊断选择错误影响正确编码以及编码员编码遗漏、错编、疾病分类规则掌握不足等。通过分析,总结术后诊断不同情况下的编码规则及适用范围,提高术后诊断编码质量。结论明确术后诊断的具体含义,合理利用编码规则,对术后情况以及所包含的特殊医疗状况进行说明,真实反映疾病或健康状态,实现精细化编码。

Objectives By analyzing the postoperative diagnosis of disease classification, to evaluating the rules of which in order to improve the accuracy of main diagnosis and coding by coders. Methods Retrieving from 2015-2017 discharge diagnosis that fit the ‘postoperative＇ diagnosis, then conducted recording based on the ICD-10 coding principles. Results Total 3695 copies of the medical records retrieved, in which 308 cases of error code, the error rate was 8.34%. Possible causes of error were： the undisciplined and incomplete name of the postoperative diagnosis, bad influence of error choice on the main diagnosis, missing or error coding by coders who were not familiar with the category of the disease coding and so on. Through analysis, we can improve the quality by summarizing the rules in different situations and scope of application. Conclusions Coding rules must be used reasonably in the context of specific meaning, it took the main diagnosis and special medical condition into account.By reflecting the truth of complex diseases or state of health, we achieved the purpose of accurate coding without omission and the purpose of refinement coding.