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目的总结流产个人史编码中存在的问题,为编码员更好的掌握流产个人史编码方法提供参考。方法从某院病案管理系统中检索国际疾病分类(ICD-10)疾病诊断编码为Z35.1,Z87.5,N96或O26.2的病例,通过电子病历系统对病历进行逐份检查。结果 112份病案中,编码有误的病案共有24份,编码错误率为20.5%,零次流产史以及妊娠伴有1次流产史的编码错误率最高,达100%,妊娠伴有2~3次流产史的编码错误率其次,在40%~43%之间,2~3次流产史不伴妊娠的编码错误率较低,在3%到14%之间。结论部分编码员仍然对复发性流产和习惯性流产的概念不清楚,并且不注意阅读病案中患者的既往史、个人史和婚育史,在编码时没有严格按照编码的查找步骤,而是过度的依赖于编码字典库进行编码,从而导致流产个人史的编码错误率较高。
Objective To summarize the problems existing in the abortion personal history coding and provide a reference for the coder to better grasp the abortion history coding method. Methods The cases with International Classification of Diseases (ICD-10) disease diagnosis code Z35.1, Z87.5, N96 or O26.2 were searched from the hospital records management system. The medical records were checked by electronic medical record system. Results Among the 112 cases, there were 24 cases of coding errors and the coding error rate was 20.5%. The coding error rate of the history of zero abortion and pregnancy with one miscarriage was the highest, reaching 100% Second, in the 40% to 43%, 2 to 3 miscarriage history of pregnancy without coding error rate is low, between 3% to 14%. Conclusions Some coders are still unclear about the concept of recurrent and habitual abortion and are not aware of the past history of patients in the medical record, their personal history, and the history of marriage and childbirth. Instead of having to follow the exact coding of the search step, Relies on the coding dictionary for encoding, resulting in higher miscoding rates of abortion personal history.