中国病案
中國病案
중국병안
Chinese Medical Record
2015年
11期
26-28
,共3页
出院诊断%编码%准确性
齣院診斷%編碼%準確性
출원진단%편마%준학성
Discharged diagnosis%Coding%Accuracy
目的：分析住院病案首页出院诊断编码的常见错误，以提高编码的准确性。方法随机抽取2014年病案，进行疾病编码检查，分析错误原因。结果500份病案共有出院诊断2825条，检查出出院诊断和编码错误共791条，错误率为28%。其中漏编码的错误比例最大，占错误率的50.06%，漏编的最主要原因是由于编码员没有详细的阅读病案。结论加强编码员阅读病案的能力、熟练掌握ICD-10编码原则、熟悉ICD-10电子字典库的内容及提高临床知识水平、增强编码员责任心、并制定奖惩措施是提高编码准确性的有效措施。
目的：分析住院病案首頁齣院診斷編碼的常見錯誤，以提高編碼的準確性。方法隨機抽取2014年病案，進行疾病編碼檢查，分析錯誤原因。結果500份病案共有齣院診斷2825條，檢查齣齣院診斷和編碼錯誤共791條，錯誤率為28%。其中漏編碼的錯誤比例最大，佔錯誤率的50.06%，漏編的最主要原因是由于編碼員沒有詳細的閱讀病案。結論加彊編碼員閱讀病案的能力、熟練掌握ICD-10編碼原則、熟悉ICD-10電子字典庫的內容及提高臨床知識水平、增彊編碼員責任心、併製定獎懲措施是提高編碼準確性的有效措施。
목적：분석주원병안수혈출원진단편마적상견착오，이제고편마적준학성。방법수궤추취2014년병안，진행질병편마검사，분석착오원인。결과500빈병안공유출원진단2825조，검사출출원진단화편마착오공791조，착오솔위28%。기중루편마적착오비례최대，점착오솔적50.06%，루편적최주요원인시유우편마원몰유상세적열독병안。결론가강편마원열독병안적능력、숙련장악ICD-10편마원칙、숙실ICD-10전자자전고적내용급제고림상지식수평、증강편마원책임심、병제정장징조시시제고편마준학성적유효조시。
Objective To analyze the common mistakes of discharged diagnosis coding existing in the home pages,so as to improve the accuracy of the coding.Methods 500 cases of medical records in 2014 were selected randomly,then conducted an examination on the diseases coding and analyze relevant reasons.ResultsThere were totally 2825 discharged diagnosis in the 500 cases of medical records,which accounted for 50.06%,and the most important reason was the coder had not read the medical records carefully.Conclusions In order to improve the coding accuracy of the coders,we should take measures such as strengthen their ability of reading medical records,master the ICD-10 coding rules,get familiar with the content of the electric dictionary,improve their clinical knowledge,strengthen their responsibility as well as formulate some rules for rewards and punishment.
