小儿腹泻病ICD-10编码探讨

目的 提高小儿腹泻病编码的准确率.方法 采用医院病案管理系统检索某院2011年1月至2013年12月出院诊断为腹泻病的病案,对病案首页填写诊断腹泻病的编码情况进行回顾性调查分析.结果 3年小儿腹泻病占全部出院患者的5.44％,其中以婴儿发病住院最高,占61.27％,其次是幼儿,占17.27％.2011年和2012年小儿腹泻病编码错选归类于K52.9现象突出.阅读复习病案发现某院实际感染性腹泻占70.49％、非感染性腹泻占29.56％.结论 小儿腹泻病编码准确率不高,医院要加强对临床医师的病案首页填写、ICD-10知识的培训,编码人员要加强与临床医师沟通,不断提高小儿腹泻病编码的准确性.

Discussion on ICD-10 Coding of Children Diarrheal Disease

Objective To improve the accuracy of infantile diarrhea disease coding. Methods Searching Diarrhoeal disease medical record between January 2011 and December 2013 by hospital medical record management system. The front sheet of medical record were retrospectively analyzed. Results Infhntile diarrhea disease patients accounted for 5.44% of all hospital patients. The highest incidence was babies, accounted for 61.27%. The second is infants, accounted for 17.27%. The phenomenon of infantile diarrhea disease coding incorrect classified as K52.9 was outstanding in 2011 and 2012. After reading medical record we found infectious diarrhea （70. 49%）, the infectious diarrhea （29. 56%）. Conclusion Infantile diarrhea disease coding accuracy is not high. The hospital should strengthen the clinicians in the front sheet of medical record fill in and training of ICD-10 knowledge. Coders should strengthen communication with clinicians, and constantly improve the accuracy of infantile diarrhea disease coding.