将住院患者的病率编码与ICD-11和ICD-10的准确性进行比较
Javad Zarei1, Reza Golpira2, Nasim Hashemi3
1Department of Health Information Technology, School of Allied Medical Sciences, Ahvaz Jundishapur University of Medical Sciences, Iran.
概括
使用国际疾病分类第11版 (ICD-11) 的临床编码精度低于使用国际疾病统计分类第10版 (ICD-10) 的临床编码精度. 全面的编码员培训和改进的文档对于成功实施ICD-11至关重要.
科学领域:
- 医疗信息学 医疗信息学
- 医疗编码系统 医学编码系统
- 临床文档 临床文档
背景情况:
- 从ICD-10过渡到ICD-11,在保持临床编码准确性方面存在挑战.
- 确保准确的编码对于可靠的健康数据和患者护理至关重要.
研究的目的:
- 为了比较ICD-11和ICD-10之间的临床编码的准确性.
- 在现实临床环境中确定编码错误的主要原因.
主要方法:
- 在两个普通医院进行的前性研究.
- 住院医疗记录被医院编码器使用ICD-11和ICD-10编码.
- 代码与五位专家导师建立的黄金标准进行了验证.
主要成果:
- 编码准确度为ICD-10的89.1%和ICD-11的74.2%.
- 最低的ICD-11准确性是在受伤,耳朵和循环系统疾病的章节中观察到的.
- 临床编码员的错误是两种编码系统不准确的主要原因 (超过79%).
结论:
- 与ICD-10相比,ICD-11编码的准确性明显低于ICD-10.
- 针对编码器需求的预实施培训和增强的医疗记录文档对于有效的ICD-11采用至关重要.
- 建议制定当地ICD-11指南和文档标准.
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