某医院脑梗死编码错误情况分析

Analyzing to coding errors of cerebral infarction in certain hospital

目的分析某医院住院病案首页中以脑梗死为主要诊断的错误编码情况,探讨原因和解决措施,旨在以此为例全面提高病案质量,为医院病案质量控制保驾护航。方法采用医院病案信息系统,以“脑梗死”为主要诊断的主导词检索时间范围在2020年10月—2021年10月的病案180份,通过重新阅读病案,根据国际疾病诊断分类原则,查找各类脑梗死的编码规则,分析总结该医院脑梗死的编码错误类型。结果编码为I63.9未特指的脑梗死病例有160份,通过仔细阅读病案发现其中110例存在编码错误,占比68.75%,其中入脑前动脉的编码错误率占比13.13%,大脑动脉占比21.26%,其他和后遗症类占比分别是16.25%和18.11%。结论脑梗死作为双分类轴心编码的疾病,编码员应通读病案,在ICD-10编码中要明确其责任血管和病因分型,以便更加准确分类到I63.0~I63.9,而非直接通过首页信息一味编码残余类目I63.9。

Objective Analyzing the coding errors on the home page of medical records,with cerebral infarction as the main diagnosis,and discuss the reasons and measures,in order to improve the quality of medical records.Methods Using the hospital medical record information system to search for the leading word with“cerebral infarction”as the main diagnosis.There are 180 medical records from October 2020 to October 2021 were retrieved.According to the principles of international classification diagnosis,re-reading the medical records,searching for various types of coding rules about cerebral infarction to analyze and summarize the coding error types of cerebral infarction in this hospital.Results There are 160 unspecified cases of cerebral infarction coded as I63.9.Reading the medical records carefully,it is found that 110 cases were coded with errors,which were accounting for 68.75%.The coding error rate of the anterior cerebral artery accounts for 13.13%,and the cerebral artery accounts for 21.26%,and the proportions of other and sequelae are 16.25% and 18.11%respectively.Conclusion Cerebral infarction is a dual-category axis-coded disease.The coder should read through the medical records and clarify its responsible blood vessel and etiological classification in the ICD-10 code,to accurately classify it into I63.0-I63.9 instead of coding residual category I63.9 directly from home page information.