骨科病案编码错误案例分析

Combined with the Case Analysis of Orthopedic Medical Record Coding Errors

目的分析某院骨科病案错误编码的原因,提高编码质量。方法调取某院骨科2018年1月1日-2018年12月31日出院病案,共623份,通过阅读病案并核对编码,统计编码错误数量及类型并进行分析。结果在调取的623份病案中,共有117份病案编码存在错误,错误率18.8%。其中编码员解剖知识缺乏、临床知识不足造成的错误占41%;编码员对编码规则掌握不清造成的错误占36%;编码员责任心不强造成的错误占10%;临床医师病案书写不规范造成的错误占13%。结论编码员医学知识欠缺、编码原则不清、责任心不高、医师病案书写不规范是导致编码错误的主要原因;编码员应提高对工作的重视程度,增加医学知识与专业知识的学习,临床医师应规范病案书写,通过编码员与临床医师共同努力提高编码质量。

Objectives This paper analyzed the causes of the wrong coding of orthopedic medical records in a hospital to improve the coding quality.Methods A total of 623 medical records were collected from the orthopedics department of a hospital from January 1st,2018 to December 31st,2018.The number and types of coding errors were counted and analyzed by reading the medical records and checking the codes.Results Among 623 medical records collected,117 medical records had errors in coding,with an error rate of 18.8%.The errors caused by lack of anatomical knowledge and lack of clinical knowledge accounted for 41%.36%of the errors caused by the coder's unclear understanding of the coding rules;Coder responsibility was not strong caused by errors accounted for 10%;Thirteen percent of errors were caused by nonstandard writing of medical records by clinicians.Conclusions The coding errors were mainly caused by lack of medical knowledge,unclear coding principles,low sense of responsibility and irregular writing of medical records.Coders should pay more attention to work,increase the study of medical knowledge and professional knowledge,clinicians should standardize the writing of medical records,and improve the coding quality through coders and clinicians'joint efforts.