600份住院病案首页ICD-10编码质量分析

Analysis of ICD-10 Code Quality on the Front Pages of 600 Inpatient Medical Records

目的 通过调查某院ICD-10编码存在的问题,寻找有效的改进措施,提高住院病案首页数据质量。方法 随机抽取某妇幼医院2020年7月1日-2020年12月31日600份出院病案,重新核查出院诊断及其ICD-10编码,进行统计分析。结果 抽查病案中疾病编码错误168份,错误率为28%,其中医师诊断不规范和错误占60.12%,编码人员自身水平问题占38.69%,信息传送问题导致的编码错误1.19%。主要诊断选择及编码错误占34.52%,其他诊断填报及编码错误占30.35%。结论 病历书写和编码员水平及系统问题造成编码存在问题,前2者是编码错误的主要原因,应从临床医师培训、提升编码员综合技能以及建立有效的沟通入手,持续提高编码准确性。

Objectives This study aims to investigate the existing problems of the ICD-10 coding in a hospital and put forward effective measures to improve the data quality of the front page of medical records. Methods 600discharge medical records from a maternal and child hospital from July 1, 2020 to December 31, 2020 were randomly selected. The discharge diagnoses and the ICD-10 codes were reexamined and were statistically analyzed.Results There were 168 cases with disease coding errors among the sampling medical records, with an error rate of 28%. 60.12%, 38.69% and 1.19% of the coding errors were caused by doctors’ non-standard and incorrect filling, coding personnel’s own level and information transmission problems, respectively. 34.52% of the cases had main diagnostic choice and coding error, and 30.35% had other diagnostic filling and coding error. Conclusions It is the common responsibility of clinicians and coders to improve the quality of the front-page data on inpatient medical records. The coding accuracy can be continuously improved by strengthening the training of clinicians, enhancing the comprehensive skills of coders and establishing effective communication.