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目的了解ICD-10中哮喘编码在某院的使用情况及编码的准确性,分析错误编码原因,探讨正确编码思路。方法总结2008版ICD-10中哮喘编码规则,通过抽取某院2014年9月-2015年2月哮喘患者126例病案,实际调阅纸质和电子病案,统计分析编码情况。结果临床医师对疾病病因、临床表现及疾病的描述程度均影响哮喘的ICD-10编码,126例病案中,分类于J45.9的117例,实际分类错误率达32%,分类于J45.0的9例病案中错误率达33%。结论通过自查或他查等方式,定期或不定期开展科室业务学习,加强编码人员的再教育;定期开展与临床科室的编码讨论,增强与临床医师的沟通;在病案信息系统中添加相应提醒程序都将有助于提高编码的准确性。
Objective To understand the use of ICD-10 asthma coding in a hospital and the accuracy of coding, analyze the reason of error coding, and explore the correct coding ideas. Methods To summarize the coding rules for asthma in 2008 edition of ICD-10, and to collect 126 medical records of asthma in a hospital from September 2014 to February 2015, and actually record paper and electronic medical records, and analyze the coding situation statistically. Results The clinicians’ description of the etiopathogenisis, clinical manifestation and disease all affected the ICD-10 coding of asthma. Among the 126 cases, 117 cases were classified as J45.9, the actual classification error rate was 32%, which was classified as J45.0 The error rate of 9 cases was 33%. Conclusion Through self-examination or other methods, regular or irregular departmental business learning to strengthen the re-education of coders; regularly carry out coding discussions with clinical departments to enhance communication with clinicians; in the medical record information system to add the corresponding reminder The program will help improve the coding accuracy.