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《Chinese Medical Record》 2018-06
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Coding Analysis of Neonatal Subependymal Hemorrhage in a Certain Third Class A Children's Hospital

Liu Ying;Zeng Yueping;Song Fei;Zhang Xin;Chen Yanhua;Yan Dongli;Beijing Children's Hospital,Capital Medical University;  
Objectives In this study,we evaluate the coding situation of neonatal subependymal hemorrhage in a child's hospital to improve the accuracy of the coding quality of that disease.Methods Retrospectively consulted medical records of inpatients who attended this children's hospital from Jan.1,2014 to Dec.31,2017.A total of 2704 inpatients' medical records were included in this study.Results The accuracy rate of subependymal hemorrhage was85.34%.In error coding,the proportion of neonatal intracerebroventricular hemorrhage and neonatal intracranial hemorrhage was the highest,accounting for 53.97% and 16.5656%,respectively,according to the name of the dictionary of the first page of the medical record management system.Conclusion The encoder should master the principle of ICD coding and understand the clinical anatomical structure so as to ensure the correctness of the first page information of the medical record.
【CateGory Index】: R743.34
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