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| Influence of admission conditions on the classification of diseases |
| Zhong Qianjun, Huang Liyan, Li Huixia. |
Department of Information,Pingshan Maternal and Child Health Care Hospital, Shenzhen 518122, China
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Abstract Objective The condition of admission on the first page of the medical record has a certain influence on the code of diagnosis of the same disease.Through retrospective analysis of 3 typical discharge disease diagnosis cases of moderate anemia, intrauterine device, and pubic symphysis of pregnancy, this paper analyzes the influence of admission conditions on the diagnostic code of the same disease, improves the accuracy of the code, and improves the quality of the data on the first page of medical records. Methods According to the basic coding rules of the International Classification of Diseases, this paper analyzed the influence of admission conditions on the diagnosis code of the same disease in three typical cases of discharge diagnosis, namely, moderate anemia, intrauterine device, and pubic symphysis separation of pregnancy. Results In the discharge diagnosis of the same disease on the first page of the medical records, the classification and coding of the disease are different according to whether the patient is diagnosed or not at the time of admission.The accuracy of admission information directly affects the accuracy of disease classification code. Conclusion Coders have to code more precisely, classifying not only the naming, nature, development, and pathology of the disease, but also the diagnosis of the disease at the time of admission. As to the diagnosis of the same disease, the admission condition is different, so the disease code is also different.
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Received: 16 May 2020
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