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目的产科系统的疾病编码复杂、难度大,编码员在编码时常常出现错误,为提高某院产科病案的疾病编码水平,回顾性调查某院编码为Z35.9、O42.9、O32-O34及O72的出院病案的疾病编码质量。方法利用病案管理系统进行检索,调出某院2014年产科编码为Z35.9、042.9、032-O34、072共1620例的出院病案进行复查。统计这四类编码错误例数与其实际使用例数的比值,得到这四类编码的错误率。结果对1620份出院病案核查,共698份编码有误。编码Z35.9共357例,错误编码298例,错误率83%;编码O42.9共425例,错误编码372例,错误率88%;编码O32-O34共488例,错误编码11例,错误率2%;编码O72共350例,错误编码17例,错误率5%。结论编码员应有高度的责任心,认真学习国际疾病分类及其相关知识,努力提高自身的专业水准和职业素养,从而提高编码水平。
Objective Obstetric system of disease coding complexity, difficult, the coder often errors, in order to improve obstetric medical records of a hospital disease coding levels, a retrospective investigation of a hospital coding Z35.9, O42.9, O32-O34 and The quality of the disease codes for discharge of O72. Methods The medical records management system was used to search and recall the discharged cases of 1620 cases with obstetric coding Z35.9,042.9,032-O34,072 in a hospital in 2014. Statistics of these four types of coding error and its actual use of the ratio of the number of cases, get the error rate of these four types of coding. Results A total of 698 codes were incorrect for the 1,620 discharged medical records. A total of 357 cases were coded Z35.9 with error coding of 298 cases, the error rate was 83%. A total of 425 cases were coded O42.9 and 372 cases were coded incorrectly, with an error rate of 88%. A total of 488 cases were coded O32-O34 with 11 cases of error codes Rate 2%; code O72 a total of 350 cases, 17 cases of error coding, the error rate of 5%. Conclusion The coder should have a high sense of responsibility, carefully study the classification of international diseases and their related knowledge, and strive to improve their professional standards and professionalism so as to raise their coding standards.