儿童结肠息肉疾病诊断与手术名称书写及编码的缺陷分析

Defects Analysis on the Diagnosis of Colonic Polyps in Children as well as the Writing and Coding of Operation Names

目的探讨儿童结肠息肉疾病诊断与手术名称书写及编码存在的问题以及改进策略。方法收集北京某三甲儿童医院2010年1月-2014年12月住院病案首页疾病诊断为结肠息肉的病案共计400例,回顾性分析病案首页中疾病诊断与手术名称的书写及编码情况。结果病案首页疾病诊断与病理诊断符合率为89.13%;疾病诊断ICD-10编码与医师书写一致,准确率为89.13%;病案首页手术名称与手术记录书写符合率为13.75%,手术ICD-9-CM-3编码与手术记录符合率为47.38%。结论医师应准确书写疾病诊断,及时参考病理诊断修正疾病诊断,根据手术内容正确书写手术名称,避免错填和漏填;编码员不应仅依据病案首页中医师书写的名称进行编码,而应当熟练掌握编码原则,仔细查阅病案,提高编码准确率。

Objectives To explore the problems existing in the diagnosis of colonic polyps in children as well as the writing and coding of operation names. Methods A total of 400 cases were collected from a Class A and Tertiary Hospital of children in Beijing from January 2010 to December 2014, and the first diagnosis of the disease was diagnosed as colonic polyps,to analyze the writing and coding of the disease diagnosis and operation in the home page. Results The rate of disease diagnosis and pathological diagnosis was 89.13%;ICD-10 coding for disease diagnosis was consistent with doctor＇s writing, and the accuracy was 89.13%;The rate of the first operation was 13.75%,The coincidence rate of ICD-9-CM-3 coding and surgical records was 47.38%. Conclusions Doctors should write the diagnosis the diseases accurately,the diagnosis of diseases should be in time with reference to pathological diagnosis. We should avoid the wrong filling and lack of operation names according to the correct content of the operations. Coders should not only encode based on the names in the front pages of medical records, but also should be familiar with the principles of coding,carefully review the medical records and improve the coding accuracy.