康复治疗影响国际疾病分类因素的分析

Analysis of the influential factors of rehabilitant therapy on the ICD-9

目的:加强临床医师和疾病分类人员对康复治疗疾病分类的认识,提高康复治疗疾病分类编码的准确性及病案资料检索利用的质量。方法:利用Foxpro建立病案资料数据库,以国际疾病分类(ICD-9)的编码原则为标准,回顾性检索1998-01/2002-12新桥医院住院进行康复治疗的病例,所有病例以出院的第1诊断为检索对象。结果:检索出康复治疗疾病分类的误码667例,主要发生在循环系统、精神疾患系统、损伤和中毒系统、神经系统、肌肉骨骼系统、影响健康状态系统(V编码)和传染病系统的疾病分类编码。结论:康复治疗疾病分类编码的准确率,直接影响临床、科研及教学对病案信息资料检索利用的质量。

AIM:To make medical staff and coding clerk strengthen the realization of medical records and coding system to the International Classification of Diseases,9th Revision, Clinical Modification (ICD 9) so as to improve the accuracy of rehabilitant therapy disease classification coding system and the quality of medical record information searches. METHODS:Using Foxpro to found medical record database, retrospective searches on the cases record of Xinqiao Hospital that took the rehabilitant therapy from 1998 01/2002 12 were done according to the ICD 9 CM, and all case took the first discharge diagnosis as searching target. RESULTS:Incorrect classification coding of rehabilitant therapy had been searched in 667 cases.Most incorrect codes came from circulation system,mental disease system, injury and poisoning system, nerve system,muscle bone system,V coding system and epidemic system. CONCLUSION:Accuracy rate of the coding system in classification of rehabilitant therapy disease directly plays an important role in the quality of medical record information search in clinical application, science research and teaching.