医院病案疾病诊断ICD编码准确性的影响因素及处理措施研究

Study on Influencing Factors and Treatment Measures of ICD Coding Accuracy in Hospital Medical Record Disease Diagnosis

目的分析使用国际疾病分类编码(International Classification of Diseases,ICD)对疾病进行标准分类准确性的影响因素并研究适当的处理对策。方法回顾性选取2021年1月—2023年12月河池市第三人民医院收治的1440例患者的临床资料,进行正规的编码流程并加以核对,分析导致编码错误的具体原因以及解决办法。结果73份病案编码错误中主要诊断选择错误12份,疑难诊断编码错误14份,未按病理报告编码18份,未按照合并编码原则10份,合并症未编码19份。73名病案编码错误科室分布中骨科15份,心血管内科18份,神经内科20份,泌尿外科10份,儿科8份,产科2份。73份病案编码错误原因中病历书写不规范25份(34.25%),主导词错误22份(30.14%),编码员业务水平不佳11份(15.07%),特殊疾病特殊编码6份(8.22%),其他9份(12.33%)。结论医院病案疾病诊断ICD编码准确性受到病历书写不规范、主导词错误、编码员业务水平不佳的影响,需提升编码员专业技术水平,减少工作中的差错,不断改进编码质量。

Objective To analyze the factors influencing the accuracy of standard classification of diseases by using International Classification of Diseases(ICD)and to study the appropriate countermeasures.Methods The data of 1440 patients dmitted to Hechi Third People's Hospital from January 2021 to December 2023 were retrospectively selected,and the normal coding process was carried out and checked,and the specific reasons and solutions leading to coding errors were analyzed.Results Among the 73 cases of medical record coding errors,12 cases were mainly wrong in diagnosis selection,14 cases were wrong in difficult diagnosis coding,18 cases were not coded according to pathological report,10 cases were not coded according to combined coding principle,and 19 cases were not coded according to complications.Among the 73 cases with wrong medical records,there are 15 cases in orthopedics,18 cases in cardiovascular medicine,20 cases in neurology,10 cases in urology,8 cases in pediatrics and 2 cases in obstetrics.Among the 73 cases of medical record coding errors,25 cases(34.25%)had irregular medical record writing,22 cases(30.14%)had errors in leading words,11 cases(15.07%)had poor professional skills of coders,6 cases(8.22%)had special coding for special diseases,and 9 cases(12.33%)had other reasons.Conclusion The accuracy of ICD coding in hospital medical record diagnosis is affected by nonstandard medical record writing,incorrect leading words and poor professional level of coders.It is necessary to improve the professional technical level of coders,reduce errors in work and continuously improve the coding quality.