CAJ | 학술논문

目的：探讨急性心肌梗死（ acute myocardial infarction，AMI）的国际疾病分类（ international classification of diseases ，ICD）编码不准确的问题，分析错误原因，制定对策。方法选取我院2013－11至2014－10住院患者出院主要诊断编码为I21．－的病历348份，从病案库房中将纸质病历调出，以人工方式对主要诊断为急性心肌梗死的病历进行逐份检查、核实。结果348份出院主要诊断编码为I21．－的病历中，总编码错误率为33．91％。结论临床医师应学习ICD－10的有关内容，掌握疾病诊断的书写规范；编码工作人员应熟悉ICD－10的结构，不断提高编码技能水平和编码的准确性。
목적：탐토급성심기경사（ acute myocardial infarction，AMI）적국제질병분류（ international classification of diseases ，ICD）편마불준학적문제，분석착오원인，제정대책。방법선취아원2013－11지2014－10주원환자출원주요진단편마위I21．－적병력348빈，종병안고방중장지질병력조출，이인공방식대주요진단위급성심기경사적병력진행축빈검사、핵실。결과348빈출원주요진단편마위I21．－적병력중，총편마착오솔위33．91％。결론림상의사응학습ICD－10적유관내용，장악질병진단적서사규범；편마공작인원응숙실ICD－10적결구，불단제고편마기능수평화편마적준학성。
Objective To investigate of acute myocardial infarction ( referred to as AMI) the problems of accuracyinICD-10 classification and coding, and analyzeits causes of error, and countermeasures.Methods 348 copies of medical records ofinpatients-from November 2013 to October 2014 in this hospital with discharge diagnosis code of I21.-,were consulted.Results In the 348 cop-ies of medical record with discharge main diagnosis coded as I21.-, the total code error rate was 33.91%.Conclusions The hospital leadership should invite experts to hold ICD-10 related lectures,so as clinicians have the opportunity to learn about the content of ICD-10, writestandard disease diagnosis, as complete and specific as possible.The coding staffshould find problems in the work hard,learn-basic knowledge of ICD-10,be familiar with ICD-10 structure, learn the relevant medical knowledge, carefully communicate with clini-cians, when necessary, to correct code, and constantly improve their coding skills.