ICD-10的编码对疾病分类统计质量的效果观察

Observation of the effect of ICD-10 coding on the statistical quality of disease classification

目的观察应用ICD-10编码对于疾病分类统计质量所起到的效果.方法回顾性选取2022年1月-2023年1月天津市北辰医院病案室中建档的胆囊炎病历200份作为研究对象,通过ICD-10编码对病历资料开展检查与核实,对于分类不准确情况进行统计,总结出现编码错误的因素,制定相应的解决方案.结果200份病历中出现编码错误14例,分析出现错误的病理类型主要为急性单纯性胆囊炎以及慢性胆囊炎.结论采取ICD-10编码可以帮助病案室管理规范化,但是因为受到疾病复发性、诊断书写不规范以及病案管理人员知识缺乏等相关因素的干扰,导致ICD-10编码错误现象依旧存在,医院需要不断提高对ICD-10编码的学习力度,加强信息管理措施,从而保证编码准确性和疾病分类统计的整体质量.

Objective To observe the effect of ICD-10 coding on the statistical quality of disease classification.Methods From January 2022 to January 2023,200 medical records of cholecystitis were retrospectively selected as the research objects.ICD-10 code was used to check and verify medical records,and the inaccurate classification was statistically analyzed.The factors causing coding errors were summarized and corresponding solutions were developed.Results There were 14 coding errors in 200 medical records.The main pathological types of errors were acute simple cholecystitis and chronic cholecystitis.Conclusion The adoption of ICD-10 coding can help standardize the management of the medical record room,but due to the interference of related factors such as disease recurrence,non-standard diagnosis writing and lack of knowledge of medical record managers,the phenomenon of ICD-10 coding errors still exists.Hospitals need to continuously improve the learning of ICD-10 coding and strengthen information management measures.Thus,the accuracy of coding and the overall quality of disease classification statistics are guaranteed.