关键词: 住院儿童, ICD-10, R编码, 主要诊断选择, 编码准确率

Abstract:

Objective: To master R encoding rules, improve the accuracy of the main diagnosis and disease encoding. Methods: The
ICD-10（R00-99 Encoding）was used as the standard, the medical record management system was applied to retrieve the 1 270
documents of a children's hospital in 2014, and the data were retrospectively analyzed. Results: There were 1 270 cases diagnosed by
R encoding, which accounted for 2.50% of the total number of hospital discharge records, and 767 cases were found to be incorrect on
the main diagnostic disease name, main diagnosis and the disease encoding selection. Conclusion: Clinicians are not familiar with the
knowledge of the international classification of disease and the principle of the main diagnostic encoding choice, the quality of
personnel and job responsibility of encoding should be strengthened.

Key words: hospitalized children, ICD-10, R encoding, the main diagnostic choice, encoding accuracy