浅谈易被忽略的“另编码”

A Brief Discussion on the Easily Neglected “Additional Code”

目的分析漏编"另编码"的因素,加强手术操作编码的完整和准确。方法通过计算机检索2012年-2013年1万份手术病案,详细了解主要手术操作的情况,根据手术分类编码原则校对编码。结果 1万份病案中,手术操作遗漏"另编码"的有2100份,占检查份数的21%。其中:由于过分依赖编码库造成漏编码1071例,占51%;培训不到位造成漏编码672例,占32%;手术记录不完整造成漏编码357例,占17%。结论编码员在编码时不仅应仔细阅读病历,还必须掌握手术编码分类原则及相关的医学知识,提高编码准确性,减少"另编码"的漏编。

Objectives To analyze the factors about the ignored coding of ＂＇additional code＂ and strengthen the integrity and accuracy of operation coding. Methods To search the 10000 cases of medical records with operations by computer from 2012 to 2013, get a detailed understanding of the main operation conditions, and check the coding according to the rules of operation classified coding. Results There were 2100 cases of medical records that neglected the ＂additional code＂ of operations in the 10000 cases of medical records, which accounted for 21% of the inspection number. Conclusions The coders should not only read the medical records carefully in the encoding, hut also grasp the principle of operation classified coding and related medical knowledge, so as to improve the accuracy of coding and decrease the neglected coding of ＂additional code＂ .