疾病和死亡外因编码存在的问题分析

目的 对病案首页中“损伤、中毒的外部原因”填写与编码存在的问题进行分析,探寻提高其准确性的有效措施.方法 回顾性分析某院近3年病案首页中“损伤、中毒的外部原因”填写信息与编码情况,对存在的问题进行汇总分析.结果 临床医生未填写“损伤、中毒的外部原因”的为259份,占缺陷病案的2.3％,不规范填写2053份,占缺陷病案18.3％,编码员遗漏编码321份,占缺陷病案2.9％,分类编码不准确1632份,占缺陷病案14.5％.结论 加强对临床医生和编码人员ICD相关知识的培训,增强质量意识,提高责任心,并加大质控力度,方可提高疾病和死亡外因编码的准确性.

Analysis on Problems Existing in the Coding of External Causes of Disease and Death

Objective To analyze the problems existing in the filling and coding of ＂External Causes of Injury, Poisoning＂ in the home pages of medical records, and investigate effective measures to improve its accuracy. Method To conduct an retrospective analysis on the filling information and coding situation of ＂External Causes of Injury, Poisoning＂ in the home pages of the hospital in recent 3 years, then summarize and analyze the problems existing. Results There were many problems such as missing filling or lack of standardization situations existing in the filling of ＂External Causes of injury, Poisoning＂ among clinicians, and the accuracy of classification coding was not satisfied. Correct coding was derived from accurate writing content at first, so the development of both doctors and staff was needed. Conclusions We should strengthen the training of ICD related knowledge among both clinicians and the coding staff, enhance the quality consciousness, improve the sense of responsibility and strengthen the intensity of quality control, then could we improve the coding accuracy of external causes of disease and death.