CN108564991A - Digitization coding case history wrong identification system based on ICD and its recognition methods - Google Patents
Digitization coding case history wrong identification system based on ICD and its recognition methods Download PDFInfo
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- G16H10/00—ICT specially adapted for the handling or processing of patient-related medical or healthcare data
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Abstract
The invention discloses a kind of, and the digitization based on ICD encodes case history wrong identification system and its recognition methods, including server, rule database and data storage are connected on the server, the server (1) is interior to log in unit, data check and correction unit at least provided with user's registration；The rule database is for preserving Y case history mistake rule；The data storage is used to preserve the digitization coding case histories to be identified such as X；Any user is after the user's registration logs in unit login, the digitization coding case histories to be identified such as X are uploaded in the data storage, digitization coding case history in the data storage is carried out wrong identification one by one by the data check and correction unit with case history mistake rule described in Y items, and obtains the error message of existing digitization coding case history.Advantageous effect：Intelligent recognition is participated in without artificial, and to the modification instruction to make mistake.
Description
Technical field
The present invention relates to medical conditions data statistics technical field, specifically a kind of digitization coding based on ICD
Case history wrong identification system and its recognition methods.
Background technology
International Classification of Diseases (international Classification of diseases, ICD) is according to disease
Certain features, disease is classified according to rule, with the method for coding come the system that indicates.ICD is that WHO is formulated
The classification of diseases method of international uniform, it is according to characteristics such as the cause of disease of disease, pathology, clinical manifestation and anatomical positions, by disease
Classify, becomes an orderly combination, the system indicated with the method for coding.The whole world it is general be the 10th
Secondary revised edition《The international statistical classification of diseases and related health problems》, the abbreviation of ICD is still remained, and be collectively referred to as ICD-
10.Acceptance system disease suborder about 9516, content is comprehensively accurate, cover the other various diseases of all sections of hospital, is domestic
Current most complete, ICD-10 own coding database query systems include mainly that ICD-10 is encoded, disease name, phonetic code.
Support the bidirectional inquiry of disease, classification, phonetic and Chinese character fuzzy query etc..
Under current big data and artificial intelligence background, medical information gradually touches the core business of medical treatment, to diagnosis and treatment
Process provide aid decision and guidance reference, but to medical information carry out digitization preservation during at least there is also with
Lower problem：
First, in recent years, DRGs technologies (Diagnosis Related Groups) are in the popularization and application in the whole nation, DRGs
Guiding theory be：By the formulation of unified medical diagnosis on disease classification quota payment standards, reach medical resource using standardization.
Help that hospital is encouraged to reinforce medical quality managent, it is to earn a profit actively to reduce cost to force hospital, shortens length of stay, subtracts
Few inductivity medical care cost, is conducive to Payment control.
And as the DRGs technologies unique data source-sufferer the Abstract of Inpatient Records data；The sufferer the Abstract of Inpatient Records
The quality of data will directly affect the reasonable compensation of the evaluation and medical income of hospital performance, or even decide DRGs Technique Popularizing works
The success or failure of work, and ICD coded datas quality is the part for weighing sufferer the Abstract of Inpatient Records quality of data core the most.So
And at this stage, there is a serious shortage of often have many mistakes, Wu Fada to professional coder in obtained coded data
To DRGs technologies to the quality standard of ICD coded datas.Therefore the prior art hinders the popularization of DRGs technologies.
Second, case history is complicated and changeable, and often a kind of disease can cause multiple complications, however doctor is when establishing case history,
All illnesss that patient can be recorded in detail, cause patient history complicated and changeable, for case history archive typing personnel, often
It will be easy to happen mistake or missing by the typing one by one of all illnesss, however for finally sorting out.
Third, since patient's illness is complicated, illness coding is directed to tens of thousands of, when carrying out digitization conversion to case history,
Easily there is a situation where coding and illnesss not to correspond to.
4th, in the prior art, when papery case history is converted to digitization case history by people, occur for digitization case history
Mistake is also rested on and is manually checked, and is equivalent to a medical record dataization conversion and at least two people even more people is needed to carry out
Typing, it is time-consuming and laborious.Even if consuming a large amount of artificial, but final input result still has many mistakes, allows medical record data
Change transformation technology and be in bottleneck stage, seriously affects the development of medical information intelligent data.
Based on above statement, the correctness of the digitization medical record data obtained after existing medical record data cannot also protect
Card, causes the reliability of digitization medical record information low, has delayed the development of medical information.
Invention content
In view of the above-mentioned problems, the digitization coding case history wrong identification system that the present invention provides a kind of based on ICD and its
Recognition methods, based on international disease classification standard and operation detailed catalogue coding, in conjunction with the mutual of sufferer the Abstract of Inpatient Records
Relationship, formulate the rule that wrong identification is carried out to digitization coding case history, which meets international disease classification standard, logarithm
It is searched and is marked according to the content for not meeting international disease classification standard in change coding case history, be convenient for medical record coder core again
It looks into, it is time saving and energy saving.
In order to achieve the above objectives, the specific technical solution that the present invention uses is as follows：
A kind of digitization coding case history wrong identification system based on ICD, key technology is to include server, described
Be connected with rule database and data storage on server, in the server at least provided with user's registration log in unit,
Data proofread unit；The rule database is for preserving Y case history mistake rule；The data storage is for preserving X
Case history is encoded etc. digitization to be identified；Any user is to be identified by X etc. after the user's registration logs in unit login
Digitization coding case history be uploaded in the data storage, data check and correction unit successively will be in the data storage
Digitization coding case history and Y items described in case history mistake rule carry out wrong identification one by one, and obtain the digitization in the presence of mistake
Encode the error message of case history.
By above-mentioned design, it is based on international disease classification standard, formulates case history corresponding with international disease classification standard
Mistake rule, after digitization coding case history is carried out comparison identification one by one with Y case history mistake rule, once it falls into any
Content as defined in case history mistake rule then illustrates to recognize mistake at one.One digitization coding case history may be with multiple case histories
Mistake rule is consistent, i.e. there may be multiple mistakes for a digitization coding case history.Wherein X and Y is just whole more than or equal to 1
Number.
Further,
Any one case history mistake rule setting has Z audit identification content；
Perhaps it is ICD disease codes, rule belonging to ICD disease chapters and sections coding, rule belonging to rule in the audit identification
Financial information, rule belonging to ICD Operation encodings, rule belonging to diagnosis and treatment process information, rule belonging to affiliated sufferer essential information, rule
Do not answer then existing ICD disease chapters and sections coding, rule that existing ICD disease codes, rule is not answered or not belonging to existing rule
Sufferer essential information, rule do not answer diagnosis and treatment process information, rule belonging to existing rule not to answer ICD operations belonging to existing rule
The ICD diseases that coding, the regular ICD disease chapters and sections coding for not answering existing financial information, rule that should include, rule should include
Diagnosis and treatment process information, the rule that disease coding, rule sufferer essential information, the rule that should include should include should include
The financial information that ICD Operation encodings, rule should include.
Wherein Z is the positive integer more than or equal to 1.The regular object to be identified of each case history mistake rule setting,
Once there is the content being consistent with case history mistake rule, then being identified object present in dataization coding case history then may be used
Mistake can occur.Case history mistake rule be according to the sufferer the Abstract of Inpatient Records content of international disease classification standard and the sufferer come
It formulates.
It further describes, the digitization coding case history is what medical record coder obtained from sufferer the Abstract of Inpatient Records
Data, the digitization coding case history include at least essential information, diagnosis and treatment process information, ICD disease codes, ICD Operation encodings
And financial information.
According to the Abstract of Inpatient Records content of the newest revision of national health department it is found that being provided with doctor in the Abstract of Inpatient Records
Treat organization names, medical way of paying, healthy card number, hospitalizations, patient's identification number, sufferer essential information, diagnostic message, Yi Shengxin
Breath, operation information, from school's formula, financial information etc..Since the Abstract of Inpatient Records is unification of the motherland format, details are not described herein.
It further describes, the case history mistake rule also sets up case history miscue content, case history errorlevel, case history
Type of error.
When an error occurs, the case history miscue content provides error indication for medical record coder, is compiled convenient for medical record
Code member modifies.Case history errorlevel is used for decision error seriousness.Case history type of error is used for error differentiating attribute.
It further describes, the case history type of error includes at least ICD disease main codes selection mistake, ICD diseases are compiled
Code mistake, ICD disease codes fill in format error, ICD disease code ranges conclude mistake, ICD disease codes exist simultaneously mistake
Accidentally, ICD disease codes do not merge mistake；
The case history type of error at least further includes ICD chief surgical procedures coding selection mistake, ICD Operation encoding mistakes
Accidentally, ICD Operation encodings fill in format error, ICD Operation encoding ranges conclude mistake, ICD Operation encodings exist simultaneously mistake,
ICD Operation encodings do not merge mistake；
The case history type of error at least further includes that essential information mistake, essential information fill in format error, essential information
Missing errors；
The case history type of error at least further include diagnosis and treatment process information errors, the format error of diagnosis and treatment process information solicitation,
Diagnosis and treatment process loss of learning mistake；
The case history type of error at least further includes that financial information mistake, financial information fill in format error, financial information
Missing errors；
The case history type of error at least further includes that essential information and diagnosis and treatment process information exist simultaneously mistake, essential information
Mistake, essential information and ICD Operation encodings, which are existed simultaneously, with ICD disease codes exists simultaneously mistake, essential information and finance letter
Breath exists simultaneously mistake, essential information and diagnosis and treatment process Asymmetry information and answers the not corresponding mistake of mistake, essential information and ICD disease codes
Accidentally, the essential information and not corresponding mistake of ICD Operation encodings, essential information and financial information do not correspond to mistake；
The case history type of error at least further includes that diagnosis and treatment process information and ICD disease codes exist simultaneously mistake, diagnosis and treatment
Procedural information and ICD Operation encodings exist simultaneously mistake, diagnosis and treatment process information and financial information and exist simultaneously mistake, diagnosis and treatment process
The information and not corresponding mistake of ICD disease codes, diagnosis and treatment process information and the not corresponding mistake of ICD Operation encodings, diagnosis and treatment process information
Mistake is not corresponded to financial information；
The case history type of error at least further includes that ICD disease codes exist simultaneously mistake, ICD diseases with ICD Operation encodings
Disease coding and financial information exist simultaneously not corresponding wrong, the ICD disease codes of mistake, ICD disease codes and ICD Operation encodings and
Financial information does not correspond to mistake；
The case history type of error at least further includes that ICD Operation encodings exist simultaneously mistake with financial information, ICD performs the operation
Coding does not correspond to mistake with financial information.
Above-mentioned case history type of error can be used different names expression, if but its type meaning belong to the above-mentioned type or
The subtype of the above-mentioned type belongs within the protection domain of the application.And above-mentioned mistake can also be according to ICD, ICD hand
The updates such as art coding, carry out adaptability update.
It further describes, the error message includes at least the case history miscue content, case history errorlevel, disease
Go through type of error and wrong case history location address；The server is according to the wrong case history location address pair and mistake disease
It goes through the corresponding digitization coding case history of location address to be labeled, the content of the mark includes case history errorlevel, case history mistake
Type and case history miscue content；The case history errorlevel passes through the mark shape of mark either label symbol or mark
Remember color either label orientation or label textual representation.
Case history miscue content is quickly modified mistake convenient for medical record coder.Case history errorlevel is for prompting
The seriousness of medical record coder's mistake.Mistake case history location address is searched and is positioned to errors present for server.
It further describes, user can carry out checking behaviour to the digitization coding case history being uploaded in the data storage
Make, delete operation and export operate.
It further describes, in order to increase and deletion rule, regular typing is additionally provided on the server and is deleted
Unit, the rule typing are used to carry out new regular typing to the case history mistake rule in the rule database to grasp with deleting unit
Make, have rules modification operation and the operation of existing redundant rule elimination.But carrying out typing operation, delete operation and modification operation
It needs to be read out the permission of user.Need the user having permission that can just carry out aforesaid operations.
It further describes, in order to realize long-range identification, improves the versatility of the system, serve more hospitals.Institute
State and be additionally provided with long-range connection unit on server, user can by the case history on intelligent terminal proofread application software or
Person's web page address carries out user's login, realizes that teledataization encodes case history wrong identification.
A kind of recognition methods of the digitization coding case history wrong identification system based on ICD, follows the steps below：
S1：Server receives the wrong identification request that any user is sent out；
S2：Server detects whether the data storage digitization coding case history to be identified such as has；If so, entering step
Rapid S3；Otherwise, return to step S1；
S3：The digitizations to be identified such as server determination encode the number of case history as X, and case history mistake is advised in rule database
Item number then is Y, and the number of the audit identification content in case history mistake rule is Z；And enable x=y=z=1；
S4：Server judges x-th etc. whether digitization coding case history to be identified meets the y articles in rule database
Z-th of audit identification content of case history mistake rule, enters step S5 if meeting, otherwise enters step S7；
S5：Server judges whether z>=Z；If so, obtaining error message, S7 is entered step；Otherwise S6 is entered step；
S6：Server enables z=z+1, return to step S4；
S7：Server judges whether y>=Y；If so, entering step S9；Otherwise S8 is entered step；
S8：Server enables y=y+1；Z=1；Return to step S4；
S9：Server judges whether x>=X；If so, wrong identification terminates；Otherwise S10 is entered step；
S10：Server enables x=x+1, y=1, z=1, and return to step S4.
During carrying out above-mentioned steps, user can carry out interrupting identification or continue to identify control, and user may be used also
Successively with interactive step, as long as whole case history identifications can be completed.
Beneficial effects of the present invention：By combing ICD reference books, foundation is refined to disease suborder coding and operation detailed catalogue is compiled
The mutual codimg logic rule base of code；First page of illness case non-coding field is combed simultaneously, between each other and between coding
Logic rules, between establishing between non-coding and non-coding, encode and encoding and coding non-coding between mutual pass
System establishes the rule for carrying out wrong identification to digitization coding case history, is established to medical record coder in conjunction with mutual relationship
Digitization coding case history carry out wrong lookup.Intelligent recognition is participated in without artificial, and to the modification instruction to make mistake.It is real
Existing big data intelligent management, improves the accuracy rate and authenticity of medical big data, reduces the workload of people.
Description of the drawings
Fig. 1 is wrong identification system structure diagram of the present invention；
Fig. 2 is the recognition methods flow chart of the digitization coding case history wrong identification system based on ICD.
1. server in figure, 2. rule databases, 3. data storages, 11. user's registrations log in unit, 12. data schools
To unit, 13. regular typings and deleting unit, 14. long-range connection units.
Specific implementation mode
Specific embodiment and working principle of the present invention will be described in further detail below in conjunction with the accompanying drawings.
It will be seen from figure 1 that a kind of digitization based on ICD encodes case history wrong identification system, it is characterised in that including
Server 1 is connected with rule database 2 and data storage 3 on the server 1, and user's note is provided in the server 1
Volume logs in unit 11, data check and correction unit 12, regular typing and deleting unit 13 and long-range connection unit 14；
The rule database 2 is for preserving Y case history mistake rule；
The data storage 3 is used to preserve the digitization coding case histories to be identified such as X；
Any user encodes disease after the user's registration logs in the login of unit 11, by the digitizations to be identified such as X
It goes through and is uploaded in the data storage 3, the data check and correction unit 12 successively compiles the digitization in the data storage 3
Code case history carries out wrong identification one by one with case history mistake rule described in Y items, and obtains in the presence of wrong digitization coding case history
Error message.
Based on international disease classification standard and operation detailed catalogue coding, in conjunction with the mutual of sufferer the Abstract of Inpatient Records
Relationship formulates the rule that wrong identification is carried out to digitization coding case history, which meets international disease classification standard, to data
The content that international disease classification standard is not met in change coding case history is searched and is marked.In the present embodiment, using
ICD-10 and ICD-9-CM-3 international disease classification standards.When international disease classification standard either national regulation occur update or
When change, can real-time update be carried out to rule database in real time, to meet International Country standard.
User application software can be proofreaded by the case history on intelligent terminal or web page address carries out user's login,
Realize that teledataization encodes case history wrong identification.
Regular typing is used to carry out new rule to the case history mistake rule in the rule database 2 to record with deleting unit 13
Enter operation or the operation of existing redundant rule elimination.
In the present embodiment, any one case history mistake rule setting has Z audit identification content；
Perhaps it is ICD disease codes, rule belonging to ICD disease chapters and sections coding, rule belonging to rule in the audit identification
Financial information, rule belonging to ICD Operation encodings, rule belonging to diagnosis and treatment process information, rule belonging to affiliated sufferer essential information, rule
Do not answer then existing ICD disease chapters and sections coding, rule that existing ICD disease codes, rule is not answered or not belonging to existing rule
Sufferer essential information, rule do not answer diagnosis and treatment process information, rule belonging to existing rule not to answer ICD operations belonging to existing rule
The ICD diseases that coding, the regular ICD disease chapters and sections coding for not answering existing financial information, rule that should include, rule should include
Diagnosis and treatment process information, the rule that disease coding, rule sufferer essential information, the rule that should include should include should include
The financial information that ICD Operation encodings, rule should include.
In the present embodiment, the digitization coding case history is what medical record coder obtained from sufferer the Abstract of Inpatient Records
Data, digitization coding case history include essential information, diagnosis and treatment process information, ICD disease codes, ICD Operation encodings and
Financial information.As other real-time modes, it can also include other in sufferer the Abstract of Inpatient Records that digitization, which encodes case history,
Content, since sufferer the Abstract of Inpatient Records is unification of the motherland standard, content is the prior art and consistent, and details are not described herein.
But when sufferer the Abstract of Inpatient Records occurs all variations such as to increase, change, delete, adaptation can be carried out.
Case history mistake rule setting case history miscue content, case history errorlevel, case history type of error.In the present embodiment
In, every case history mistake rule further includes number of regulation, and the language of each rule is the language that server can identify.
In the present embodiment, the case history type of error includes at least ICD disease main codes selection mistake, ICD diseases
Format error is filled in code error, ICD disease codes, ICD disease code ranges conclude mistake, ICD disease codes exist simultaneously
Mistake, ICD disease codes do not merge mistake；
Wherein, ICD diseases main code selection mistake can be：The principal disease coding selection mistake of Died Patients is asked
Topic, special coding selection mistake etc.；
ICD disease codes mistake can be：Tumour code error, drug and disease mismatch mistake etc..
ICD disease codes fill in format error：ICD disease code None- identifieds mistake, disease code are not belonging to
ICD code errors, beyond threshold range mistake etc..
ICD disease code ranges conclude mistake：The clear remaining classification code error of case history, case history classification error are asked
Topic, special disease coding sort out mistake, special sufferer coding sorts out mistake etc..
ICD disease codes exist simultaneously mistake：ICD disease codes cannot simultaneous mistake；ICD diseases
Necessary simultaneous mistake of coding etc..
The case history type of error at least further includes ICD chief surgical procedures coding selection mistake, ICD Operation encoding mistakes
Accidentally, ICD Operation encodings fill in format error, ICD Operation encoding ranges conclude mistake, ICD Operation encodings exist simultaneously mistake,
ICD Operation encodings do not merge mistake；
Wherein ICD Operation encodings mistake may be that surgical procedure coding is omitted, surgical procedure encodes or surgical procedure title
Missing etc..ICD Operation encoding ranges conclude mistake ICD Operation encodings and conclude unclear or conclude wrong.
The case history type of error at least further includes that essential information mistake, essential information fill in format error, essential information
Missing errors；
The case history type of error at least further includes that financial information mistake, financial information fill in format error, financial information
Missing errors；
Financial information mistake can be in apparent excessive or very few mistake of expense etc.；
Financial information fill in format error can be information position fill in mistake, there are mistakes etc. for information format.
The case history type of error at least further include diagnosis and treatment process information errors, the format error of diagnosis and treatment process information solicitation,
Diagnosis and treatment process loss of learning mistake；
The case history type of error at least further includes that essential information and diagnosis and treatment process information exist simultaneously mistake, essential information
Mistake, essential information and ICD Operation encodings, which are existed simultaneously, with ICD disease codes exists simultaneously mistake, essential information and finance letter
Breath exists simultaneously mistake, essential information and diagnosis and treatment process Asymmetry information and answers the not corresponding mistake of mistake, essential information and ICD disease codes
Accidentally, the essential information and not corresponding mistake of ICD Operation encodings, essential information and financial information do not correspond to mistake；The case history mistake
Type at least further includes that diagnosis and treatment process information and ICD disease codes exist simultaneously mistake, diagnosis and treatment process information and ICD operations and compile
Code exists simultaneously mistake, diagnosis and treatment process information and financial information and exists simultaneously mistake, diagnosis and treatment process information and ICD disease codes not
The not corresponding mistake of corresponding mistake, diagnosis and treatment process information and ICD Operation encodings, diagnosis and treatment process information and the not corresponding mistake of financial information
Accidentally；
The case history type of error at least further includes that ICD disease codes exist simultaneously mistake, ICD diseases with ICD Operation encodings
Disease coding and financial information exist simultaneously not corresponding wrong, the ICD disease codes of mistake, ICD disease codes and ICD Operation encodings and
Financial information does not correspond to mistake；
The case history type of error at least further includes that ICD Operation encodings exist simultaneously mistake with financial information, ICD performs the operation
Coding does not correspond to mistake with financial information.
The above-mentioned mistake that exists simultaneously can be two or exist while coding more than two, can also be single coding
In the presence of, can also be two or more must exist simultaneously and cannot be specified with other coding the mistake coexisted.
In the present embodiment, the error message includes at least the case history miscue content, case history errorlevel, disease
Go through type of error and wrong case history location address；
The server 1 is according to the mistake case history location address pair digitization corresponding with the mistake case history location address
Coding case history is labeled, and the content of the mark includes in case history errorlevel, case history type of error and case history miscue
Hold；
The case history errorlevel passes through the mark shape of mark either label symbol or marker color or label side
To or label textual representation.
The case history errorlevel is divided according to error severity.
In the present embodiment, user can check the digitization coding case history being uploaded in the data storage 3
Operation, modification operation, delete operation, export operate and can carry out data statistics and data analysis.
In the present embodiment, rule database 2 is divided into coding and coding rule library, coding and non-coding rule base, non-
Coding and non-coding rule base.
As it can be seen from table 1 being needed in practical applications for the corresponding word rule of part rule in rule database 2
Word rule is converted into the language that computer can identify, is stored in rule database 2.
The corresponding word rule list of 1 rule database part of table rule
As it can be seen from table 1 serial number 111, audit identification content 1 is ICD disease codes belonging to rule： A86or
G04.9, audit identification content 2 is ICD disease codes belonging to rule：B05 is Main Diagnosis, if related with measles, should encode to
B05.0+G05.1*, case history errorlevel are 2, and case history type of error is ICD disease code mistakes.
Then when any dataization encodes in case history, ICD disease codes include A86or G04.9, B05, then system can should
Case identifies, it is believed that is the case in the presence of mistake, and error message is labeled in corresponding case.
Serial number 112, audit identification content 1 is ICD disease codes belonging to rule：M83；Audit identification content 2 is rule
Affiliated ICD disease codes：E55；Case history miscue content, which is M83 and E55, to be existed simultaneously；Case history errorlevel is 1；Disease
Going through type of error is：ICD disease codes exist simultaneously mistake.
Then when including simultaneously M83 and E55 in any case, then illustrate that there are mistakes for the case.Case history type of error is ICD
Disease code exists simultaneously mistake.
Serial number 113, audit identification content 1 is ICD disease codes belonging to rule：O；Audit identification content 2 is regular institute
Belong to sufferer essential information：Age≤10 year old；Case history miscue content is：O codings should not occur in underage child；Case history mistake etc.
Grade is 2；Case history type of error：Essential information and ICD disease codes do not correspond to mistake；
In any case, age information is：Age≤10 year old, and there are when ICD disease code O, then illustrate the case
There are mistake, the case history miscue content that medical record coder gets is：O codings should not occur in underage child；And it points out
Type of error is that essential information and ICD disease codes do not correspond to mistake, causes to encode incorrect.
Serial number 114, audit identification content 1 is ICD Operation encodings belonging to rule：08.44 except 08.4；In audit identification
Hold 2 for ICD Operation encodings belonging to rule：08.6 or 08.7；Case history miscue content is：Coding should be merged to 08.44；Case history
Errorlevel is 2；Case history type of error：ICD Operation encodings do not merge mistake.
Serial number 115, audit identification content 1 is ICD Operation encodings belonging to rule：13.1and cataract；In audit identification
Hold 2 for ICD disease codes belonging to rule：Diagnosis is free of (H25-H28) and cataract；Case history errorlevel is：2；Case history mistake
Type：Surgical procedure encodes and disease code mismatch problem.
Serial number 116, audit identification content 1 is ICD Operation encodings belonging to rule：50.4；Audit identification content 2 is rule
ICD Operation encodings belonging to existing rule are not answered：From school's formula 50.5 are not present not equal to death and surgical procedures coding；Disease
Going through miscue content is：Full hepatectomy should have transplanting coding 50.5；Case history errorlevel is 1；Case history type of error：It answers
Simultaneous surgical procedure encoded question；
Serial number 117, audit identification content 1 is ICD disease codes belonging to rule：C51-C58, female sex organ are pernicious
Tumour；Audit identification content 2 is sufferer essential information belonging to rule：Gender=man；Case history miscue content is：Male patient
This coding should not occur；Case history errorlevel is 1；Case history type of error：Essential information and ICD disease codes do not correspond to mistake.
Serial number 118, audit identification content 1 is ICD Operation encodings belonging to rule：O82or O84.2；Audit identification content
2 do not answer ICD Operation encodings belonging to existing rule for rule：ICD Operation encodings are free of 74.0-74.1；In case history miscue
Rong Wei：Cesarean section delivery should have Cesarean operation；Case history errorlevel is 1；Case history type of error：ICD Operation encoding mistakes.
Serial number 119, audit identification content 1 is ICD Operation encodings belonging to rule：ICD Operation encodings contain (00-84) and
Operative category=1 (Operative category=1 represents Operative category as surgical procedure)；Audit identification 2 financial information of content：Without operation
Cost information；Case history miscue content is：ICD Operation encodings should be existed simultaneously with surgery cost information；Case history mistake etc.
Grade is 1；Case history type of error ICD Operation encodings do not correspond to mistake with financial information.
In the present embodiment, case history mistake rule item number is related to up to ten thousand, does not repeat one by one herein.
A kind of recognition methods of the digitization coding case history wrong identification system based on ICD, in conjunction with Fig. 2 as can be seen that pressing
It is carried out according to following steps：
S1：Server 1 receives the wrong identification request that any user is sent out；
S2：Server 1 detects whether the data storage 3 the digitization coding case history to be identified such as has；If so, into
Step S3；Otherwise, return to step S1；
S3：The digitizations to be identified such as the determination of server 1 encode the number of case history as X, and case history is wrong in rule database 2
Accidentally the item number of rule is Y, and the number of the audit identification content in case history mistake rule is Z；And enable x=y=z=1；
S4：Server 1 judges x-th etc. whether digitization coding case history to be identified meets the in rule database 2
Z-th of audit identification content of y case history mistake rule, enters step S5 if meeting, otherwise enters step S7；
S5：Server 1 judges whether z>=Z；If so, obtaining error message, S7 is entered step；Otherwise S6 is entered step；
S6：Server 1 enables z=z+1, return to step S4；
S7：Server 1 judges whether y>=Y；If so, entering step S9；Otherwise S8 is entered step；
S8：Server 1 enables y=y+1；Z=1；Return to step S4；
S9：Server 1 judges whether x>=X；If so, wrong identification terminates；Otherwise S10 is entered step；
S10：Server 1 enables x=x+1, y=1, z=1, and return to step S4.
Wherein, X, Y, Z are positive integer more than or equal to 1, once user by regular typing and deleting unit 13 to rule
Y value with increase or reduces when case history mistake rule is either deleted in 2 typing of database.User imports in data storage 3
Digitization coding case history can be voluntarily arranged according to the size of data storage 3.And in identification process, user can at any time in
Only identification process.If the wrong place of identified digitization coding case history, carries out corresponding mark, server 1 is simultaneously
Identified amount is completed in prompt.The case for having completed identification is understood convenient for user, avoids repetitive operation.
Digitization for completing identification encodes case history, and export may be selected in user.And user can also be to data storage 3
The digitization coding case history of middle preservation is carried out continuing addition and be deleted.
It should be pointed out that it is limitation of the present invention that above description, which is not, the present invention is also not limited to the example above,
What those skilled in the art were made in the essential scope of the present invention changes, is modified, adds or replaces, and also answers
It belongs to the scope of protection of the present invention.
Claims (10)
1. a kind of digitization based on ICD encodes case history wrong identification system, it is characterised in that including server (1), the clothes
Rule database (2) and data storage (3) are connected on business device (1), the server (1) is interior at least provided with user's registration
Log in unit (11), data check and correction unit (12)；
The rule database (2) is for preserving Y case history mistake rule；
The data storage (3) is used to preserve the digitization coding case histories to be identified such as X；
Any user encodes case histories after the user's registration logs in unit (11) login, by the digitizations to be identified such as X
It is uploaded in the data storage (3), the data check and correction unit (12) is successively by the data in the data storage (3)
Change coding case history and carry out wrong identification one by one with case history mistake rule described in Y items, and obtains the digitization coding disease in the presence of mistake
The error message gone through.
2. the digitization according to claim 1 based on ICD encodes case history wrong identification system, it is characterised in that：Arbitrarily
One case history mistake rule setting has Z audit identification content；
Perhaps it is belonging to ICD disease codes, rule belonging to ICD disease chapters and sections coding, rule belonging to rule in the audit identification
Financial information, rule belonging to ICD Operation encodings, rule belonging to diagnosis and treatment process information, rule belonging to sufferer essential information, rule are not
Answer existing ICD disease chapters and sections coding, rule that existing ICD disease codes, rule is not answered or not sufferer belonging to existing rule
Essential information, rule do not answer diagnosis and treatment process information, rule belonging to existing rule that ICD operations belonging to existing rule is not answered to compile
The ICD diseases that code, the regular ICD disease chapters and sections coding for not answering existing financial information, rule that should include, rule should include
The ICD that diagnosis and treatment process information, the rule that sufferer essential information that coding, rule should include, rule should include should include
The financial information that Operation encoding, rule should include.
3. the digitization according to claim 1 based on ICD encodes case history wrong identification system, it is characterised in that：It is described
Digitization coding case history is the data that medical record coder obtains from sufferer the Abstract of Inpatient Records, and the digitization coding case history is extremely
Include essential information, diagnosis and treatment process information, ICD disease codes, ICD Operation encodings and financial information less.
4. the digitization according to claim 1 or 2 or 3 based on ICD encodes case history wrong identification system, feature exists
In：The case history mistake rule also sets up case history miscue content, case history errorlevel, case history type of error.
5. the digitization according to claim 4 based on ICD encodes case history wrong identification system, it is characterised in that：It is described
Case history type of error includes at least ICD disease main codes selection mistake, ICD disease codes mistake, ICD disease codes fill in lattice
Formula mistake, ICD disease code ranges conclude mistake, ICD disease codes exist simultaneously mistake, ICD disease codes do not merge mistake；
The case history type of error at least further includes ICD chief surgical procedures coding selection mistake, ICD Operation encodings mistake, ICD
Operation encoding fills in format error, ICD Operation encoding ranges conclude mistake, ICD Operation encodings exist simultaneously mistake, ICD operations
Coding does not merge mistake；
The case history type of error at least further includes essential information mistake, essential information fills in format error, essential information lacks
Mistake；
The case history type of error at least further includes diagnosis and treatment process information errors, the format error of diagnosis and treatment process information solicitation, diagnosis and treatment
Procedural information missing errors；
The case history type of error at least further includes financial information mistake, financial information fills in format error, financial information lacks
Mistake；
The case history type of error at least further includes essential information and diagnosis and treatment process information exist simultaneously mistake, essential information and
ICD disease codes exist simultaneously mistake, essential information and ICD Operation encodings and exist simultaneously mistake, essential information and financial information
It exists simultaneously mistake, essential information and diagnosis and treatment process Asymmetry information and answers the not corresponding mistake of mistake, essential information and ICD disease codes
Accidentally, the essential information and not corresponding mistake of ICD Operation encodings, essential information and financial information do not correspond to mistake；
The case history type of error at least further includes that diagnosis and treatment process information and ICD disease codes exist simultaneously mistake, diagnosis and treatment process
Information and ICD Operation encodings exist simultaneously mistake, diagnosis and treatment process information and financial information and exist simultaneously mistake, diagnosis and treatment process information
With the not corresponding mistake of ICD disease codes, diagnosis and treatment process information and the not corresponding mistake of ICD Operation encodings, diagnosis and treatment process information and wealth
Business Asymmetry information answers mistake；
The case history type of error at least further includes that ICD disease codes exist simultaneously mistake with ICD Operation encodings, ICD diseases are compiled
Code exists simultaneously the not corresponding mistake of mistake, ICD disease codes and ICD Operation encodings, ICD disease codes and finance with financial information
Asymmetry information answers mistake；
The case history type of error at least further include ICD Operation encodings with financial information exist simultaneously mistake, ICD Operation encodings with
Financial information does not correspond to mistake.
6. the digitization according to claim 4 based on ICD encodes case history wrong identification system, it is characterised in that：It is described
Error message includes at least the case history miscue content, case history errorlevel, case history type of error and wrong case history position
Set address；
The server (1) is compiled according to the mistake case history location address pair digitization corresponding with the mistake case history location address
Code case history is labeled, and the content of the mark includes case history errorlevel, case history type of error and case history miscue content；
The case history errorlevel by the mark shape of mark either label symbol or marker color or label orientation or
Person marks textual representation.
7. the digitization according to claim 6 based on ICD encodes case history wrong identification system, it is characterised in that：User
The digitization coding case history that be uploaded in the data storage (3) can be carried out checking that operation, delete operation and export operate.
8. the digitization according to claim 1 based on ICD encodes case history wrong identification system, it is characterised in that：Institute
It states and is additionally provided with regular typing and deleting unit (13) on server (1), which is used for deleting unit (13) to institute
The case history mistake rule in rule database (2) is stated to carry out new regular typing operation, have rules modification operation and existing rule
Then delete operation.
9. the digitization according to claim 1 based on ICD encodes case history wrong identification system, it is characterised in that：Institute
It states and is additionally provided with long-range connection unit (14) on server (1), user can be proofreaded by the case history on intelligent terminal and be answered
User's login is carried out with software or web page address, realizes that teledataization encodes case history wrong identification.
10. a kind of recognition methods of the digitization coding case history wrong identification system based on ICD as claimed in claim 2,
It is characterized in that following the steps below：
S1：Server (1) receives the wrong identification request that any user is sent out；
S2：Server (1) detects whether the data storage (3) the digitization coding case history to be identified such as has；If so, into
Step S3；Otherwise, return to step S1；
S3：Server (1) determines etc. that the number of digitization coding case history to be identified is X, case history mistake in rule database (2)
The item number of rule is Y, and the number of the audit identification content in case history mistake rule is Z；And enable x=y=z=1；
S4：Server (1) judges x-th etc. whether digitization coding case history to be identified meets the y in rule database (2)
Z-th of audit identification content of case history mistake rule, enters step S5 if meeting, otherwise enters step S7；
S5：Server (1) judges whether z>=Z；If so, obtaining error message, S7 is entered step；Otherwise S6 is entered step；
S6：Server (1) enables z=z+1, return to step S4；
S7：Server (1) judges whether y>=Y；If so, entering step S9；Otherwise S8 is entered step；
S8：Server (1) enables y=y+1；Z=1；Return to step S4；
S9：Server (1) judges whether x>=X；If so, wrong identification terminates；Otherwise S10 is entered step；
S10：Server (1) enables x=x+1, y=1, z=1, and return to step S4.
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