CAJ | 학술논문

目的：探讨宫内节育器诊断编码，提高医疗保健机构保健编码质量。方法检索某院自2012年5月到2015年4月间的出院诊断为宫内节育器的病案，对病案进行回顾性分析，依据ICD-10国际疾病编码分类原则，进行再编码。结果总计检索出1347份病案，其中，宫内节育器错误编码合计270例，错误率达20.04%。主要错误原因有临床医师诊断名称书写不规范、编码员没有联系病历前后记录进行编码、编码员对疾病编码分类掌握不足，编码不完全等。通过分析，对宫内节育器诊断有了进一步的认识，并给予匹配对应的ICD编码。结论加强病案首页疾病诊断与手术操作名称的完整、规范填写，编码员培养良好的阅读病案习惯、熟练掌握国际疾病分类方法、强化查阅疾病编码书籍的能力，才能提高编码准确性。
목적：탐토궁내절육기진단편마，제고의료보건궤구보건편마질량。방법검색모원자2012년5월도2015년4월간적출원진단위궁내절육기적병안，대병안진행회고성분석，의거ICD-10국제질병편마분류원칙，진행재편마。결과총계검색출1347빈병안，기중，궁내절육기착오편마합계270례，착오솔체20.04%。주요착오원인유림상의사진단명칭서사불규범、편마원몰유련계병력전후기록진행편마、편마원대질병편마분류장악불족，편마불완전등。통과분석，대궁내절육기진단유료진일보적인식，병급여필배대응적ICD편마。결론가강병안수혈질병진단여수술조작명칭적완정、규범전사，편마원배양량호적열독병안습관、숙련장악국제질병분류방법、강화사열질병편마서적적능력，재능제고편마준학성。
Objective To evaluate the coding of intrauterine device(IUD),so as to improve the quality of coding in the health care organizations.Methods Retrieving from May 2012 to April 2015 discharge diagnosis contains “IUD”medical records which were retrospectively analyzed by rule.Then conducted recoding based on the ICD-10 coding principles.Results Total 1347 copies of the medical records retrieved,in which 270 cases of error code,the error rate was 20.04%.Possible causes of error were:the not standardized name of the “IUD” diagnosis,there is not contact before and after when coding; coders are not familiar with the category of the disease coding and so on.Through analysis,we have a better understanding on the diagnosis of IUD and then matching the right ICD coding.Conclusions Strengthen the fully and normatively filling the diagnosis and surgical operation name of medical records,while coders should trying to develop the good reading habits of the medical records and master the methods of international classification of diseases.By this way,the coders can accurately encode according to read the medical records in contexts.