标题：医院病案首页中疾病编码错误原因分析与对策

      作者：梁喜，刘丹丹，梁小敏    高州市人民医院病案管理科，广东 高州 525200

      卷次： 2020年31卷6期

      【摘要】 目的 分析医院病案首页中疾病主要诊断编码错误的原因，探讨提高疾病编码准确性的应对策略，以提高医院信息服务质量。方法 按照国际疾病分类的编码原则，随机抽取高州市人民医院2016年1月至2018年12月15 000份病案进行编码检查，分析疾病编码错误情况、导致错误出现的原因以及应对策略。结果 15 000份病案进行编码检查结果显示，1 419份病案出现编码错误，占9.5%，其中主要诊断选择错误以及疑难诊断编码错误分别占错误病案的26.0%、22.91%；对1 419例编码错误病案进行分析发现，未按照 ICD-10编码原则造成错误是导致疾病编码错误的主要原因，共计504例，占35.5%，而产科是错误率发生最高的科室，占25.2%。结论 临床医师对疾病相关知识掌握不足以及编码人员综合素质不高是导致疾病编码错误的主要原因。因此，需要加强临床医师以及编码人员专业知识的学习，不断拓宽学习的深度与宽度，增强其工作责任心，以提高疾病编码质量。
      【关键词】 疾病编码；原因；影响因素；错误分析；对策
      【中图分类号】 R197.323 【文献标识码】 A 【文章编号】 1003—6350（2020）06—0760—03

Cause analysis and countermeasure study of disease coding errors on the first page of the medical record.
LIANGXi, LIU Dan-dan, LIANG Xiao-min. Department of Medical Record Management, Gaozhou People's Hospital, Gaozhou525200, Guangdong, CHINA
【Abstract】 Objective To analyze the causes of errors in the main diagnosis code of the disease of the hospitaland explore the countermeasures of improving the accuracy of the disease code, so as to improve the quality of hospi-tal information services. Methods According to the coding principles of the International Classification of Diseases,15 000 medical records of Gaozhou People's Hospital from January 2016 to December 2018 were randomly selectedfor coding inspection, and the diseases coding errors, the causes of the errors, and coping strategies were analyzed.Results The results of coding examination of 15 000 medical records showed that 1 419 medical records had codingerrors, accounting for 9.5%, of which the main diagnosis selection errors and difficult diagnosis coding errors account-ed for 26.0% and 22.91% respectively; the analysis of 1 419 medical records with coding errors found that the mainreason for the coding errors was the failure to follow the ICD-10 coding principle, totaling 504 cases, accounting for35.5%. Department of obstetrics has the highest error rate, accounting for 25.2%. Conclusion The lack of mastery ofdisease-related knowledge by clinicians and the low overall quality of coding personnel are the main causes of diseasecoding errors. Therefore, it is necessary to strengthen the study of the professional knowledge of clinicians and codingpersonnel, continuously expand the depth and breadth of learning, and enhance their sense of responsibility to improvethe quality of disease coding.
      【Key words】 Disease code; Cause; Influencing factor; Error analysis; Countermeasure·短篇论著·doi:10.3969/j.issn.1003-6350.2020.06.025