影响心内膜炎ICD-10分类准确性因素分析

Analysis of Factors Affecting the Accuracy of ICD-10 Classification in Endocarditis

目的:了解ICD-10中心内膜炎编码在某院的使用情况及编码的准确性,分析编码错误原因,探讨正确编码思路。方法:总结第二版ICD-10中心内膜炎编码规则,通过抽取某院2017年心内膜炎患者67例病案,实际调阅纸质和电子病案,统计分析编码情况。结果:临床医师对疾病的描述程度以及编码人员对心内膜炎分类规则的把握均影响心内膜炎的ICD-10编码,67例病案中,分类于I33.0的57例中,实际分类错误率达21%,分类于Q25.0的2例中错误率达100%,分类于J98.4的2例中错误率达100%,另外还有分类于I61.9中的1例、Q21.0中的1例、Q23.1中的1例,I08.3中的3例。结论:完善病案质控环节管理,通过自查或者他查等方式,加强编码员的责任心;熟练掌握心内膜炎的分类规则,开展科室业务学习,加强理论培训;开展与临床科室的编码讨论,增强与临床医师的联系,了解最新诊断信息;在病案管理系统中设置提醒程序,提高编码的准确性。

Objective:To understand the use and accuracy of ICD-10 central encode for endocarditis in a hospital,and to analyze the reasons for error coding,and to investigate the correct encoding ideas. Methods:The second edition of ICD-10 central encode rule was summarized,and the paper and electronic record of 67 cases of endocarditis were extracted from a hospitalin 2017.The edcoding situation was analyzed. Results:The description extent of the disease from the clinicians and the coding staff’s grasp of the classifica tion rules of endocarditis affected the encoding accuracy of endocarditis. Of the 67 cases,57 cases were classified in I33.0,with an er ror rate of 21 %. The error rate of 2 cases classified in Q25.0,2 cases classified in J98.4,1 in I61.9,1 in Q21.0,and 1 in Q23.1 was 100%. Conclusions:Through improving the management of case quality control and strengthening the coders’responsibility,through strengthening theoretical learning of classification rule and carrying out cooperation between coders and clinicians,the accuracy of ICD-10 encoding for endocarditis could be improved.