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ICD-10编码在慢阻肺患者病案管理中的应用效果

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目的 探究ICD-10编码在慢阻肺患者病案管理中的应用效果。方法 选取2023年1—6月某院书写不规范的病案进行分析和统计,针对出现的问题采取针对性的解决措施,观察应用ICD-10编码后病案管理发生的改变。结果 1277例病案中出现的主要问题为诊疗信息错误,其他手术或操作漏填、错填、多填,主要诊断选择错误、笼统、漏填,其他诊断漏填、错填、多填对应的占比分别为14。8%、11。7%、10。2%。结论 将ICD-10编码应用在慢阻肺患者病案管理中可以进一步完善疾病数据质量管理体系,为医护人员的日常工作提供便利。
Application Effect Observation of ICD-10 Coding in Medical Record Management of Patients with Chronic Obstructive Pulmonary Disease
Objective To explore application effect of ICD-10 coding in medical record management of patients with chronic obstructive pulmonary disease.Methods The paper chose medical records with non-standard writing in a certain hospital from January 2023 to June 2023 for analysis and statistics,took targeted solutions for the problems,and observed the changes in medical record management after application of ICD-10 coding.Results The main problems of 1277 medical records was incorrect diagnosis and treatment information,with corresponding proportions of 14.8%,11.7%,and 10.2% for other surgical or operation names,discharge main diagnoses,and other diagnoses.Application ICD-10 coding can effectively improve the quality of medical record management.Conclusion ICD-10 coding can further improve disease data quality management system and facilitate daily work of medical staff during medical record management of patients with chronic obstructive pulmonary disease.

ICD-10 codeChronic obstructive pulmonary diseaseMedical record managementApplication effect

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河源市人民医院,广东 河源 517000

ICD-10编码 慢阻肺 病案管理 应用效果

2024

智慧健康

智慧健康

ISSN:
年,卷(期):2024.10(28)