3例产科编码的质量分析

Quality Analysis of Three Obstetric Codes

目的通过回顾性调查某院编码为O98.8且含B95.1、O28.3及O03.9且Z37.0的出院病案的疾病编码质量。监测某院产科病案疾病编码质量,寻求提高编码质量的方法。方法利用广东省病案管理系统进行检索,调出某院2018年产科编码为O98.8且B95.1、O28.3及O03.9且Z37.0共549例出院病案。结合电子病例系统、相关文献等资料,对病例进行复查、校正。结果对549出院病案核查,共407例编码有误。编码O98.8且B95.1共46例,错误编码46例,错误率100%;编码O28.3共501例,错误编码359例,错误率72%;编码O03.9且Z37.0共2例,错误编码2例,错误率100%。结论临床知识欠缺是导致编码错误的主要原因,对ICD-10的文字理解不透切也是编码错误的重要原因,所以编码员除了要不断提高医学知识,了解医学新进展外,还要理解ICD-10文字的含义,只有这样才能保证编码的准确。

Objective To retrospectively investigate the quality of disease coding of discharged medical records with codes of O98.8 and B95.1,O28.3,O03.9 and Z37.0 in a hospital and to monitor the coding quality of obstetric medical records in a hospital and to find ways to improve the coding quality.Methods The medical record management system of Guangdong Province was used to retrieve 549 discharged cases with obstetric codes of O98.8 and B95.1,O2 8.3,O03.9 and Z37.0 in a hospital in 2018.Combined with electronic case system and related documents,the cases were reviewed and corrected.Results A total of 407 code errors were found in 549 discharged medical records.There were 46 cases of coding O98.8 and B95.1,46 cases of error coding,the error rate was 100%;501 cases of coding O2 8.3,359 cases of error coding,the error rate was 72%;2 cases of coding O03.9 and Z37.0,2 cases of error coding,the error rate was 100%.Conclusion Lack of clinical knowledge is the main cause for coding errors.Imperfect understanding of ICD-10 text is also an important cause for coding errors.Therefore,besides improving medical knowledge and understanding new medical progress,coders should also understand the meaning of ICD-10 text thoroughly.Only in this way can the coding accuracy be guaranteed.