肿瘤外科手术名称分级与编码管理现状及对策

Status quo and countermeasures about the operation name classification and code management in tumor surgery

目的了解肿瘤外科手术名称分级及编码管理的现状及弊端,分析原因并寻找对策。方法统计2014年11月1日至2015年10月31日的19 473台次手术名称数据,筛选出未经系统进行手术分级和准确编码的手术条目并分析其原因。结果共有52台次(0.27%)手术名称未进行手术分级,原因分别为手术名称字典库无可对应手术名称(24台次)、自编术式导致无法分级(12台次)、人工录入手术名称时输入错误(11台次)、系统乱码(5台次);共有52台次(0.27%)手术名称编码缺失,缺失原因分别为错录导致无对应编码30台次、因字典库无手术名称及编码21台次、系统乱码1台次;98台次(0.50%)手术名称编码错误。结论肿瘤外科手术名称字典库尚不完善,肿瘤外科的手术名称分级和编码目前尚未形成统一的标准。临床应针对目前手术名称分级及编码管理的弊端采取相应对策,制定适合肿瘤外科的手术名称分级管理及编码系统,构建信息化手术名称分级管理模式、创新肿瘤外科手术名称编码,不断完善肿瘤外科手术名称分级与编码管理,实现医院手术分级管理,保证医疗质量及医疗安全。

Objective To explore the current status and problems of the operation name classification and code management,so as to find the causes and countermeasures.Methods The names of 19 473 operations conducted between November 1,2014 and October31,2015 were screened to find out those that were not classified and encoded by the system and the causes were analyzed.Results Totally 52operations（0.27%）were not classified in the system;the causes included no corresponding operation names in the database（24operations）,self-invented surgical method（12operations）,input error of manual entry（11operations）,messy code in the system（5operations）.Moreover,another 52（0.27%）operations had no matched codes,among which,30 were due to input errors,21 due to no corresponding operation names in the system and 1due to messy code in the system.The names and codes of98 operations were found wrong.Conclusion The operation name dictionary database of tumor surgery requires further improvement and the standards for classification and encoding has not established.Measures should be taken to fight the errors and defects in operation name classification and coding management of tumor surgery,so as to realize hierarchical management of operations and guarantee quality and safety of medical service.