新生儿相关情况ICD-10编码质量分析

Analysis of ICD-10 Coding Quality for Neonates

目的分析某院宫内生长异常新生儿疾病编码情况,探讨胎龄、出生体重、身长及相关关系对新生儿ICD-10编码影响,提高编码准确率。方法收集2017年1月1日-2017年12月31日某院ICD-10编码为P05.1、P07和P08的出院病案538份,查阅病案资料,检查编码正误。结果共查出136份漏编病例,漏编率25.3%,其中P05.1漏编率46.3%,P07.-漏编率19.1%,P08.1漏编率47.5%,P08.0/P08.2漏编率14.2%。造成漏编的主要原因是编码员未理解P05.1、P07和P08的含义及它们之间的关系,P05.1仅用于早产(19.9%)、P05.1仅用于足月产和过期产(7.4%)、P08.1仅用于过期产(20.6%)、P05.1与P07.-未同时编码(41.2%)和P08.0/P08.1与P08.1未同时编码(11.0%)。结论新生儿相关情况ICD-10编码质量仍存在问题,对与妊娠期(胎龄)长短和胎儿生长有关的疾患编码时,应仔细阅读病案,明确临床诊断,确定胎龄、出生体重及二者之间的关系,以提高编码准确性。

Objectives The disease coding of newborns with abnormal growth in utero in a hospital was analyzed to explore the influence of gestational age,birth weight,body length and correlation on the icd-10 coding of newborns,so as to improve the coding accuracy.Methods 538 medical records with icd-10 codes of P05.1,P07 and P08 were collected from January 1 st,2017 to December 31 st,2017 in a hospital.Data of medical records were consulted to check whether the codes were correct or not.Results A total of 136 cases were identified,with a miss rate of 25.3%,including miss rate of P05.1 was 46.3%,P07.-was 19.1%,P08.1 was 47.5%,and P08.0/P08.2 with a miss rate of 14.2%.The main causes of missing encoding are that the coders do not understand the meaning of P05.1,P07 and P08 and their relationship,such as P05.1 was only used for premature delivery(19.9%),P05.1 was only used for term and expired delivery(7.4%),P08.1 was only used for expired delivery(20.6%),P05.1 and P07.-not simultaneously coded(41.2%)and P08.0/P08.1 and P08.1 were not simultaneously coded(11.0%).Conclusions The quality of the ICD-10 coding for neonatal conditions was still a problem.When coding for diseases related to gestation period(gestational age)and fetal growth,medical records should be carefully read to clarify clinical diagnosis,determine gestational age,birth weight and the relationship between them,so as to improve the accuracy of coding.