临床手术与病案首页手术统计差异原因分析

The Reasons and Countermeasures for the Disunity of the Nomenclatures of Day Surgeries between Two Systems

目的病案首页数据统计的结果和临床科室基于病案手术记录的统计结果有所差异,深入分析原因并提出解决措施。方法检索2017年1月1日-2017年12月31日功能神经外科的微创神经介入镇痛日间手术记录75例,对编目后手术操作名称例数进行统计描述,通过电话调查和查阅病案查明原因。结果微创神经介入镇痛术经过编码员编码,手术名称、手术编码、手术操作属性、手术级别有所不同。名称会转换为椎管内止痛剂注入术,有39例,占52%。结论医师申请手术名称与病案中手术记录内容不同,两者存在一对多的关系,编码员也会出现未真实反映手术记录内容的错误。熟悉字典库并向上级部门反映缺陷,促进编码员、统计员与医务管理者沟通,从而确保统计结果准确。

Objectives To find out the reasons and put forward the measures, the disunity of the nomenclatures and codes of day surgeries between medical record front page system and surgical anesthesia system were investigated. Methods The data of 75 cases of minimally invasive interventional analgesia during 24 h in 2017 were retrieved and checked. The statistical description and inference, Fisher＇s exact test, were used. The reasons were found out by telephone survey and medical record review. Results The nomenclatures changed during cataloguing. The distribution of cases was statistically significant（P0.05）. The reason was that doctors and nurses mistakenly fill in, the system dictionary library was updated slowly, and there was no uniform coding rule. Conclusions The training and publicity for medical staff should be increased, dictionaries should be maintained regularly, and uniform coding rules should be develop regularly.