头盆不称的诊断和ICD-10编码的准确性

目的探讨我院以头盆不称为指征的剖宫产中,诊断及ICD-10编码的准确性。方法采用回顾性研究方法,对北京市门头沟区医院2002年1月至2012年1月以头盆不称为指征施行剖宫产术的576例患者的临床资料进行分析。结果 576例病例中有357例诊断正确,219例诊断错误,头盆不称诊断的正确率为62.0%,编码的准确率也为62.0%,医生诊断笼统写成头盆不称,编码员就编为头盆不称。结论医生正确诊断头盆不称是提高编码准确性的关键。

Diagnosis and Accurate ICD-10 coding of Cephalopelvic Disproportion

Objective To discuss the accuracy of diagnosis and International Classification of Diseases 10 code of al cesarean section for the purpose of cephalopelvic disproportion.Methods Analyzing retrospectively 576 typical cases from January 2002 to January 2012 of al cesarean section for the purpose of cephalopelvic disproportion. Results The diagnosis of 357 cases were right,219 cases were wrong.Accuracy rate of the diagnosis of cephalopelvic disproportion was 62.0%.Accuracy rate of the code is also 62.0%.The diagnosis was general written cephalopelvic disproportion.The diagnosis was coded cephalopelvic disproportion.Conclusion Accurate diagnosis cephalopelvic disproportion is a key to improve accuracy of code.