Objective To analyze the factors influencing the accuracy of standard classification of diseases by using International Classification of Diseases(ICD)and to study the appropriate countermeasures.Methods The data of 1 440 patients dmitted to Hechi Third People's Hospital from January 2021 to December 2023 were retrospectively se-lected,and the normal coding process was carried out and checked,and the specific reasons and solutions leading to coding errors were analyzed.Results Among the 73 cases of medical record coding errors,12 cases were mainly wrong in diagnosis selection,14 cases were wrong in difficult diagnosis coding,18 cases were not coded according to patho-logical report,10 cases were not coded according to combined coding principle,and 19 cases were not coded accord-ing to complications.Among the 73 cases with wrong medical records,there are 15 cases in orthopedics,18 cases in cardiovascular medicine,20 cases in neurology,10 cases in urology,8 cases in pediatrics and 2 cases in obstetrics.Among the 73 cases of medical record coding errors,25 cases(34.25%)had irregular medical record writing,22 cases(30.14%)had errors in leading words,11 cases(15.07%)had poor professional skills of coders,6 cases(8.22%)had special coding for special diseases,and 9 cases(12.33%)had other reasons.Conclusion The accuracy of ICD coding in hospital medical record diagnosis is affected by nonstandard medical record writing,incorrect leading words and poor professional level of coders.It is necessary to improve the professional technical level of coders,reduce errors in work and continuously improve the coding quality.
关键词
病案疾病诊断/病案ICD-10编码准确性/影响因素
Key words
Medical record disease diagnosis/Accuracy of medical record ICD-10 coding/Influencing factor
维普
万方数据