摘要
为提高皮肤软组织缺损编码的准确性,本文搜集2014年1月1日-2018年12月31日皮肤软组织缺损在某院临床的案例,对425份住院病案编码进行回顾性分析,发现101份皮肤软组织缺损编码错误,编码错误率为23.76%。结合具体案例总结了三种导致编码错误的原因:混淆造成皮肤软组织缺损的原因,忽略了创伤性皮肤软组织缺损部位的特殊性及损伤类型的特殊性。通过总结提出编码员可通过规范编码流程、灵活运用专业知识、定期总结、加强与临床医师的沟通等方面提高自身编码水平。
In order to improve the accuracy of skin and soft tissue injuries coding, a hospital reviewed its home page of skin and soft tissue injuriefrom January 1, 2014 to December 31, 2018. 101 out of 425 medical records have coding errors, with an error rate of 23.76%.Three causes of coding errors are summarized: confusing skin and soft tissue injuries causes;ignoring skin and soft tissue injuries anatomy;ignoring the special types of traumatic skin and soft tissue injuries. It is proposed that coders can improve their coding level by standardizing the coding process, using professional knowledge flexibly, summarizing regularly and strengthening communication with clinicians.
作者
曾芳
蒋莉
张静
金敏
刘慧悦
Zeng Fang;Jiang Li;Zhang Jing;Jin Min;Liu Huiyue(Institute of Hospital Management,Xiangya Hospital of Central South University,Changsha 410013,Hu'nan Province,China;不详)
出处
《中国病案》
2020年第8期38-40,共3页
Chinese Medical Record
基金
中南大学湘雅医院医院管理研究基金项目(2017GL01)。
