| 孙东珠1，牟怡平2，张文2▲，郭艺萍2，张娟3，李明姬1.消化道出血患者ICD-10编码在病案首页应用的准确性分析[J].中国医药科学,2025,(2):163-167 基金项目:陕西省提升公众科学素质研究计划项目[2020PSL（Y）044]。 |
| 消化道出血患者ICD-10编码在病案首页应用的准确性分析 |
| Accuracy analysis of ICD-10 coding for patients with gastrointestinal hemorrhage in the first page of medical records |
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| DOI： |
| 中文关键词: 消化道出血；病因；ICD-10编码；准确性 |
| 英文关键词:Gastrointestinal hemorrhage; Cause; ICD-10 coding; Accuracy |
| 作者 | 单位 | | 孙东珠1，牟怡平2，张文2▲，郭艺萍2，张娟3，李明姬1 | 1.西北大学第一医院病案室，陕西西安 710043；2.西安交通大学第一附属医院医疗信息管理办公室，陕西西安 710061；3.西安交通大学第一附属医院消化内科，陕西西安 710061 |
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| 中文摘要: |
| [摘要] 目的 评价某三甲医院病案首页中消化道出血患者国际疾病分类（ICD）编码的准确性。 方法 提取西安交通大学第一附属医院2020—2021年病案首页临床主要诊断描述包含“消化道出血”字段的病案资料，以临床诊断为金标准，判断临床诊断与ICD-10编码是否一致，计算消化道出血ICD-10编码的灵敏度、特异度、阳性预测值和阴性预测值，并分析编码假阳性和假阴性问题。 结果 814例消化道出血患者中被ICD-10编码识别有明确病因的患者共321例，其中编码真阳性319例，假阳性2例，编码假阴性224例，编码真阴性269例，总错误编码率为27.8%（226/814）。消化道出血ICD-10编码的灵敏度为58.7%、特异度为99.3%、阳性预测值为99.4%、阴性预测值为54.6%，灵敏度和阴性预测值偏低，特异度和阳性预测值较高。226例错误编码中，有14例因医师书写问题导致编码错误，占比6.2%（14/226），212例为编码员问题导致编码错误，占比93.8%（212/226）。 结论 消化道出血患者编码按分类规则，当查到病因时要按病因编码，使ICD-10编码更准确标识消化道出血病因及部位。编码员在日常工作中应加强临床知识及疾病分类规则学习，提高工作责任心，注重与临床沟通合作，以提高编码准确性。 |
| 英文摘要: |
| [Abstract] Objective To evaluate the accuracy of the international classification of diseases (ICD) coding for patients with gastrointestinal hemorrhage in the first page of medical records in a grade A tertiary hospital. Methods The medical record data of the First Affiliated Hospital of Xi’an Jiaotong University which included the field of "gastrointestinal hemorrhage" in the description of the main clinical diagnosis from 2020 to 2021 were extracted. Taking clinical diagnosis as the gold standard, whether the clinical diagnosis was consistent with ICD-10 coding was judged. The sensitivity, specificity, positive predictive value and negative predictive value of ICD-10 coding for gastrointestinal hemorrhage were calculated, and the problems of false positive and false negative coding were analyzed. Results Among 814 patients with gastrointestinal hemorrhage, 321 cases were identified with clear cause by ICD-10 coding, including 319 cases with true positive coding, 2 cases with false positive coding, 224 cases with false negative coding and 269 cases with true negative coding. The total error coding rate was 27.8% (226/814). The sensitivity, specificity, positive predictive value and negative predictive value of ICD-10 coding for gastrointestinal hemorrhage were 58.7%, 99.3%, 99.4% and 54.6%, respectively. The sensitivity and negative predictive value were relatively low, while the specificity and positive predictive value were relatively high. Among 226 cases of wrong coding, 14 cases were caused by doctors’ writing problems, accounting for 6.2% (14/226), and 212 cases were caused by coders, accounting for 93.8% (212/226). Conclusion Patients with gastrointestinal hemorrhage should be coded according to the classification rules, and when the cause is found, it should be coded according to the cause, so that ICD-10 coding can more accurately identify the cause and location of gastrointestinal hemorrhage. Coders should strengthen the study of clinical knowledge and disease classification rules in their daily work, improve their sense of responsibility, and pay attention to communication and cooperation with clinic to increase the coding accuracy. |
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