Z编码的使用分析及对策

Analysis and Countermeasures of Z Code

国际疾病分类第21章Z编码(Z00-Z99)是最后分类章,用于归类影响健康状态和与保健机构接触的因素。Z编码由于与ICD-10的其他章节差别较大,同时涉及到内外妇儿等多个临床科室,使用率较高,故在实际编码工作中较易出现问题。通过病案回顾分析的方式,对部分Z编码的使用进行分析,指出易错编码、漏编码的情况,有效结合编码原则与病案首页诊疗信息基础上作出正确编码。医疗机构应当通过专业培训提升编码员技术能力,加强编码员与临床医师的双向沟通等措施,不断提高编码准确性,为开展卫生信息统计、医疗质量管理、DRGs工作,提供高质量的数据信息。

Chapter 21 Z code of international classification of diseases(Z00-Z99) is the final classification chapter, which is used to classify the factors affecting the state of health and the contact with health care institutions.It is mainly set up for the health "patients" who come into contact with medical institutions for a particular purpose and those who have health problems. Z code is quite different from other chapters of ICD-10, and involves multiple clinical departments such as internal and external women and children, with a high utilization rate, so it is easy to have problems in actual coding. Through the retrospective analysis of medical record, this paper discusses the use of some Z codes, points out the cases of easy miscoding and omission of coding, and gives the correct coding based on the effective combination of coding principles and medical record information. Medical institutions should improve the ability of coders through internal and external training, strengthen two-way communication between coders and clinicians and other measures, and constantly improve the coding accuracy, so as to show the overall picture of medical record more succinct, and provide high-quality data information for health information statistics, medical quality management and DRGs development.