中国病案
中國病案
중국병안
Chinese Medical Record
2015年
9期
37-39
,共3页
流产个人史%ICD-10%编码
流產箇人史%ICD-10%編碼
유산개인사%ICD-10%편마
Abortion personal history%ICD-10%Coding
目的：总结流产个人史编码中存在的问题，为编码员更好的掌握流产个人史编码方法提供参考。方法从某院病案管理系统中检索国际疾病分类（ICD-10）疾病诊断编码为Z35.1，Z87.5，N96或O26.2的病例，通过电子病历系统对病历进行逐份检查。结果112份病案中，编码有误的病案共有24份，编码错误率为20.5%，零次流产史以及妊娠伴有1次流产史的编码错误率最高，达100%，妊娠伴有2～3次流产史的编码错误率其次，在40%～43%之间，2～3次流产史不伴妊娠的编码错误率较低，在3%到14%之间。结论部分编码员仍然对复发性流产和习惯性流产的概念不清楚，并且不注意阅读病案中患者的既往史、个人史和婚育史，在编码时没有严格按照编码的查找步骤，而是过度的依赖于编码字典库进行编码，从而导致流产个人史的编码错误率较高。
目的：總結流產箇人史編碼中存在的問題，為編碼員更好的掌握流產箇人史編碼方法提供參攷。方法從某院病案管理繫統中檢索國際疾病分類（ICD-10）疾病診斷編碼為Z35.1，Z87.5，N96或O26.2的病例，通過電子病歷繫統對病歷進行逐份檢查。結果112份病案中，編碼有誤的病案共有24份，編碼錯誤率為20.5%，零次流產史以及妊娠伴有1次流產史的編碼錯誤率最高，達100%，妊娠伴有2～3次流產史的編碼錯誤率其次，在40%～43%之間，2～3次流產史不伴妊娠的編碼錯誤率較低，在3%到14%之間。結論部分編碼員仍然對複髮性流產和習慣性流產的概唸不清楚，併且不註意閱讀病案中患者的既往史、箇人史和婚育史，在編碼時沒有嚴格按照編碼的查找步驟，而是過度的依賴于編碼字典庫進行編碼，從而導緻流產箇人史的編碼錯誤率較高。
목적：총결유산개인사편마중존재적문제，위편마원경호적장악유산개인사편마방법제공삼고。방법종모원병안관리계통중검색국제질병분류（ICD-10）질병진단편마위Z35.1，Z87.5，N96혹O26.2적병례，통과전자병력계통대병력진행축빈검사。결과112빈병안중，편마유오적병안공유24빈，편마착오솔위20.5%，령차유산사이급임신반유1차유산사적편마착오솔최고，체100%，임신반유2～3차유산사적편마착오솔기차，재40%～43%지간，2～3차유산사불반임신적편마착오솔교저，재3%도14%지간。결론부분편마원잉연대복발성유산화습관성유산적개념불청초，병차불주의열독병안중환자적기왕사、개인사화혼육사，재편마시몰유엄격안조편마적사조보취，이시과도적의뢰우편마자전고진행편마，종이도치유산개인사적편마착오솔교고。
Objective To summarize the problems existing in the coding of personal history of abortion patients, and provide reference for the coders to acquire the coding methods. Methods The medical cases with diagnosis coding of Z35.1,Z87.5,N96 or O26.2 in ICD-10 were searched out from the medical records management system of a hospital, then conducted inspection on each of the medical records through the electronic medical records system. Results In the 112 cases of medical records, there were 24 cases existing coding errors, and the error rate was 20.5%, the coding error rates of patients without abortion history or only once were highest, reached 100%, the coding error rates of gestation patients with two or three times of abortion history ranked the second place, which was 40% to 43%, the patients without gestation with two or three times of abortion history had low coding error rate, which was 3%to 14%. Conclusions Some of the coders had not clear understanding on the conception of recurrent abortion and habitual abortion, and missed the previous history, personal history and marital history in the medical records of the patients, so they performed the coding over depending on dictionary database without strict accordance with the coding steps, which led to the high error rate of the coding of abortion personal history.
