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| Retrospective analysis of coded cases of obstetric breech delivery |
| Zheng Ya, Xu Minhui, Jin Ni , He Guobin, Wu Lijuan |
| Jinhua Municipal Central Hospital, Jinhua 321000, China |
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Abstract Objective To analyze the accuracy of ICD-10 coding for the disease diagnosis associated with the breech delivery, so as to improve the quality of ICD coding on the first page of medical records.Methods All breech delivery medical records with ICD-10 codes of O32.1, O64.1, O80.1 or O83.1 in our hospital from 2016 to 2022, were retrieved through the medical records statistical system. The disease codes of patients diagnosed after discharge were reviewed according to ICD-10 disease coding rules, and the code of medical records was analyzed retrospectively.Results Out of 695 medical records, 88 cases had the wrong discharge diagnosis codes, and the error rate was 12.66%.Conclusion In order to improve the accuracy of disease coding, hospitals and departments should strengthen professional training for disease coders. The coders should strengthen the learning of specialized professional knowledge. After the division of labor is adjusted in coding departments, it is necessary to strengthen communication with each other, and actively communicate with clinical departments, strive to improve the accuracy of the hospital′s medical record homepage coding, and restore each medical record more truthfully.
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Received: 08 October 2023
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