在ICD-10-CM下,损伤的外部原因编码完整性的变化
Christine C Stewart1, Gregory Simon2, Brian K Ahmedani3
1Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA.
概括
伤害原因编码通过ICD-10-CM得到了改进,但发生率各不相同. 国家授权促进了外部原因的记录,强调需要验证数据的完整性以预防伤害.
科学领域:
- 公共卫生 公共卫生
- 医疗信息学 医疗信息学
- 伤害预防 预防伤害
背景情况:
- 准确的伤害原因数据对于有效的预防策略至关重要.
- 从历史上看,伤害原因编码的完整性受到ICD-9-CM要求的限制.
- 过渡到ICD-10-CM和先进的编码软件旨在提高数据的准确性.
研究的目的:
- 评估外部损伤原因代码记录的完整性.
- 评估需要额外的外部原因代码的诊断的编码实践.
- 检查ICD-10-CM.采用后的趋势.
主要方法:
- 分析来自10个卫生系统的电子健康记录和索赔数据 (2015年10月至2021年12月).
- 包括住院和紧急情况与初级伤害诊断的接触.
- 计算与有效的外部伤害原因代码相遇的比例.
主要成果:
- 大多数卫生系统都显示出高的伤害原因编码率 (超过85%的ED,超过75%的住院患者).
- 在不同地点观察到编码完整性的显著差异.
- 国家授权与持续较高的外部原因记录率有关.
结论:
- 在ICD-10-CM采用后,伤害原因编码的完整性得到了改进.
- 在大多数地点,编码完整性在研究期间略有增加.
- 编码完整性的经验性确定对于伤害预防计划至关重要,因为持续的变化.
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