目的 探讨汕头潮南民生医院癫痫疾病国际疾病分类(international classification of diseases，ICD)-10编码质量改进方案效果，并就持续改进提出建议。方法 回顾性分析2021—2023年汕头潮南民生医院不同科室门诊及住院患者癫痫疾病的诊断病案共949份，均为主要编码。其中2021年330份病案，2022年313份病案，2023年306份病案。分析2021—2023年不同科室癫痫疾病ICD-10编码准确率。结果 2021、2022、2023年，儿科病案编码准确率分别为41。08％、74。71％、88。06％，神经内外科病案编码准确率分别为89。05％、96。99％、94。44％，其他科室病案编码准确率分别为37。50％、66。67％、40。00％，不同科室编码准确率比较，差异有统计学意义(P<0。05);其中神经内外科的编码准确率最高，儿科的编码准确率次之，其他科室最低。2021—2023年全院癫痫疾病ICD-10编码总准确率逐年上升，自60。91％提升至84。03％，再提升至89。87％，差异有统计学意义(P<0。05)。结论 为提升ICD-10编码的准确性，必须加强对临床医师的分类知识及诊断书写标准的培训，同时提高编码人员的专业知识水平并增强其责任心。这将有助于提高ICD-10编码的准确性和规范性，进而促进医疗服务的质量和效率的提升。
Quality Analysis of ICD-10 Coding for Epileptic Disorders in a Hospital and Recommendations
Objective To explore the effectiveness of a quality improvement programme for international classification of diseases (ICD)-10 coding of epilepsy disorders in Shantou Chaonan Minsheng Hospital and to make recommendations for continuous improvement. Methods A total of 949 cases of epileptic diseases diagnosed in outpatients and inpatients in different departments of Shantou Chaonan Minsheng Hospital from 2021 to 2023 were retrospectively analyzed,all of which were main codes. Of these,330 medical records in 2021,313 medical records in 2022 and 306 medical records in 2023. The ICD-10 coding accuracy rate of epilepsy diseases in different departments from 2021 to 2023 was analyzed. Results In 2021,2022 and 2023,the coding accuracy of pediatric medical records was 41.08％,74.71％ and 88.06％,the coding accuracy of neurosurgery medical records was 89.05％,96.99％ and 94.44％,and the coding accuracy of medical records of other departments was 37.50％,66.67％ and 40.00％,respectively,the coding accuracy rate of different departments was compared,and the difference was statistically significant (P<0.05). With the highest coding accuracy in neurosurgery,the second highest in paediatrics,and the lowest in other departments in the other departments. From 2021 to 2023,the total coding accuracy rate of ICD-10 for epilepsy in the whole hospital increased year by year,from 60.91％ to 84.03％ and then to 89.87％,the difference was statistically significant (P<0.05). Conclusion To enhance the accuracy of ICD-10 coding,it is necessary to strengthen the training of clinicians in classification knowledge and diagnostic writing standards,as well as to improve the professional knowledge of coders and enhance their accountability. This will help improve the accuracy and standardisation of ICD-10 coding,which in turn will promote the quality and efficiency of medical services.
万方数据
维普
