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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。
Objective To analyze the common mistakes in the first hospital outpatient diagnosis code in order to improve the accuracy of coding. Methods A total of 2014 medical records were randomly selected for examination of disease codes to analyze the causes of errors. Results There were 2825 outpatients diagnosed in 500 cases, 791 cases were diagnosed and coded incorrectly, and the error rate was 28%. Among them, the largest percentage of error codes leaked, which accounts for 50.06% of the error rate. The most important reason for missed codes is that the coders did not read the detailed medical records. Conclusion Enhancing the coder’s ability to read the medical record, mastering the ICD-10 coding principle, being familiar with the content of ICD-10 electronic dictionary and improving the clinical knowledge, enhancing the responsibility of the coder and making reward and punishment measures are effective measures to improve the coding accuracy .