慢性肾功能衰竭ICD-10编码质量调查分析

目的通过调查我院慢性肾功能衰竭的ICD-10编码质量,提高我院ICD-10编码的准确性。方法根据慢性肾衰竭的临床分期,结合ICD-10编码规则,回顾性对我院2009年1月1日至2011年12月31日所有出院的慢性肾衰竭病例编码质量逐一调查分析。结果调查的慢性肾衰竭病例有495例,编码错误149例,误码率30.1%。错误编码原因由于出院诊断太笼统,编码人员对专科知识掌握不够,对慢性肾衰竭的临床分期不清楚,没有仔细查阅病案,只笼统地根据出院诊断编码,分类原则不熟练等原因。结论加强临床医师的国际疾病分类知识及诊断书写标准培训,提高编码人员的专业知识水平及加强责任心,方能提高ICD-10编码的准确性。

Analysis on Quality Investigation about Chronic Renal Failure ICD-10 Coding

Objective Through investigating ICD-10 coding quality of chronic renal failure,it aims at improving the accuracy of ICD-10 coding.Methods According to clinical stages of chronic renal failure with combing ICD-10 coding principles,this paper had a retrospective analysis on coding quality of chronic renal failure discharged from January 1,2009 to December 31,2011.Results There are 495 cases of chronic renal failure in investigation,in which 149 cases have coding error whose rate of error coding is 30.1%.The reasons of wrong coding include too general discharged diagnosis,inadequate professional knowledge,unclear about clinical stages and unskilled about classification principles of the coding-staffs,just giving coding according to discharged diagnosis without carefully reading medical records.Conclusions In order to improve the accuracy of ICD-10 coding,this paper suggests strengthening the classification knowledge and diagnosis writing standard training for clinical doctors and improving professional knowledge level and responsibility of coding-staffs.