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目的通过分析某院慢性肾脏病终末期血液透析患者疾病诊断和手术操作编码的质量情况,从而提高疾病诊断和手术操作编码的准确性。方法利用病案管理系统检索出某院2014年-2015年血液透析患者住院病案共311例,通过重新逐一查阅核对住院病案首页等相关病案资料内容,统计出有98份病案共计254个错误。对2014年1月-2014年12月及2015年1月-2015年12月的编码质量进行对比分析,统计方法为描述性统计。结果 2015年血液透析患者相关诊断及手术操作编码错误情况明显好于2014年,错误率由64.57%下降到35.43%。其中疾病诊断编码错误前3位是:肾透析并发症,错误22个(占19.74%);慢性肾脏病5期,错误20个(占17.70%);损伤中毒,错误18个(占15.93%)。手术操作编码错误前3位是:静脉插管,错误30个(占21.28%);肾透析的动静脉造瘘术,错误25个(占17.73%);静脉穿刺,错误23个(占16.31%)。结论编码错误的原因主要是编码员对ICD-10内容掌握不透彻,对医学知识欠缺,还需加强相关方面知识的学习,在工作中加强编码质量控制,提高疾病诊断和手术操作编码的准确性。
OBJECTIVE To improve the accuracy of disease diagnosis and surgical operation by analyzing the quality of disease diagnosis and surgical operation coding of patients with end-stage hemodialysis of chronic kidney disease in a hospital. Methods A total of 311 inpatient cases of hemodialysis patients in a hospital from 2014 to 2015 were retrieved using the medical record management system. A total of 254 errors were recorded in 98 medical records by re-checking the first page of in-patient cases and other related medical records. Comparing the coding quality between January 2014-December 2014 and January 2015-December 2015, the statistical methods are descriptive statistics. Results In 2015, the coding error of diagnosis and operation of hemodialysis patients was significantly better than that of 2014, and the error rate dropped from 64.57% to 35.43%. Among them, the first three cases were: the dialysis complication of kidney, 22 errors (19.74%), 20 chronic diseases (17.70%), 18 injuries (15.93%), . The first three errors in surgical operation were: venous cannulation, 30 errors (accounting for 21.28%); arterial-venous ostomy in renal dialysis with 25 errors (17.73%); venipuncture, 23 errors (accounting for 16.31% ). Conclusions The main reason for coding errors is that the coder has not mastered the content of ICD-10, lack of medical knowledge, but also needs to strengthen the learning of related knowledge, enhance the quality control of coding and improve the accuracy of disease diagnosis and surgical operation coding .