目的 探讨急性心肌梗死(acute myocardial infarction,AMI)的国际疾病分类(international classification of diseases,ICD)编码不准确的问题,分析错误原因,制定对策。方法 选取我院2013-11至2014-10住院患者出院主要诊断编码为I21.- 的病历348份,从病案库房中将纸质病历调出,以人工方式对主要诊断为急性心肌梗死的病历进行逐份检查、核实。结果 348份出院主要诊断编码为I21.-的病历中,总编码错误率为33.91%。结论 临床医师应学习ICD-10的有关内容,掌握疾病诊断的书写规范;编码工作人员应熟悉ICD-10的结构,不断提高编码技能水平和编码的准确性。

Objective To investigate of acute myocardial infarction (referred to as AMI) the problems of accuracyinICD-10 classification and coding, and analyzeits causes of error, and countermeasures. Methods 348 copies of medical records ofinpatientsfrom November 2013 to October 2014 in this hospital with discharge diagnosis code of I21.-,were consulted. Results In the 348 copies of medical record with discharge main diagnosis coded as I21.-, the total code error rate was 33.91%. Conclusions The hospital leadership should invite experts to hold ICD-10 related lectures,so as clinicians have the opportunity to learn about the content of ICD-10, writestandard disease diagnosis, as complete and specific as possible.The coding staffshould find problems in the work hard,learnbasic knowledge of ICD-10,be familiar with ICD-10 structure, learn the relevant medical knowledge, carefully communicate with clinicians, when necessary, to correct code, and constantly improve their coding skills.