某院231份眼科手术编码缺陷分析

Analysis of 231 Ophthalmic Surgery Coding Defects in a Hospital

目的分析核查某院眼科手术编码情况,探讨编码缺陷的原因,提高眼科手术编码的正确率。方法随机抽取某院2017年1月1日-2018年12月31日231份进行手术治疗的眼科住院病案,由资深编码员和临床医师组成检查小组,逐份核查分析手术操作编码情况。结果 231份眼科手术病案主要手术选择错误8例,错误率为3.46%;手术编码错编25例,错误率10.82%;手术编码遗漏5例,错误率2.16%。结论编码员应当熟练掌握编码规则,不断积累临床知识,养成严格按照步骤查找核对编码、阅读分析病案的良好习惯。同时,通过加强对临床医师的病案书写规范化培训以及建立有效的质控体系,不断提高手术操作编码质量。

Objective To analyze and verify the surgical coding of ophthalmology in a hospital,and to explore the causes of coding defects and to improve the correct rate of ophthalmic surgery coding.Methods A total of 231 ophthalmic inpatient medical records of a hospital from January 1,2017 to December 31,2018 were randomly selected.A senior coder and clinician formed an inspection team to check and analyze the operation coding.Results In 231 ophthalmic surgery cases,the main surgical selection was wrong in 8 cases,with an error rate of3.46%;the surgical code was miscoded in 25 cases,with an error rate of 10.82%;the surgical coding was missed in 5 cases and the error rate was 2.16%.Conclusion The coder should be proficient in coding rules,continuously accumulate clinical knowledge,and develop a good habit of strictly following the steps to find and check codes,read and analyze medical records.At the same time,by strengthening standardized training for clinicians’ writing of medical records and establishing an effective quality control system,Improve the coding quality of ophthalmic surgery operations.