Abstract：Objective To explore the related factors affecting the accuracy of disease coding in our hospital, and to propose intervention measures. Methods A total of 100 cases of coding errors in the Qingyuan Traditional Chinese Medicine Hospital from January 2017 to January 2019 were selected. The type of coding errors and the cause of the error were analyzed, and intervention measures was proposed accordingly. Results One hundred erroneous codes types include primary diagnostic selection code(32.00%),tumor code(28.00%),intractable syndrome code(23.00%)and complication code (17.00%). One hundred cases of coding errors were caused by poor handwriting (20.00%), unstandardized writing(13.00%), indistinct main diagnosis (22.00%), unclear external causes (5.00%), improper format (8.00%), poor qualified coding staffs (12.00%), non-standard coding procedures (12.00%), and incomplete word stock of code (8.00%).Conclusion The primary diagnostic selection code, tumor code, intractable syndrome code, and complication code are the types of disease coding errors in our hospital. The accuracy of disease coding in our hospital is not comprehensively related to physicians, coding staffs and word stock. Related intervention measures can improve the accuracy of disease coding and provide reference for clinical work.
Alkureishi MA ，Lee WW，Lyons M，et al.Impact of electronic medical record use on the patient-doctor relationship and communication：a systematic review[J].J Gen Intern Med，2016，31（5）：548-560.
[6]
Goyal A，Gluckman TJ，Tcheng JE.What′s in a name？ The new ICD-10（10threvision of the International Statistical Classification of diseases and related health problems）codes and type 2 myocardial infarction[J].Circulation，2017，136（13）：1180.
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