某院心外科主动脉疾病手术编码分析

Analysis of Operation Code of Aortic Disease in Cardiac Surgery Department of a Hospital

目的对某院心外科主动脉疾病住院病案首页手术编码进行分析,以提高手术编码质量。方法选取北京市某三甲医院2019年9月1日至2021年1月31日心外科住院病案首页中主要诊断为主动脉夹层(I71.0);主动脉动脉瘤(I71.1-I71.9);主动脉根部病变、主动脉溃疡(I77.8);非风湿性主动脉瓣狭窄(I35.0),非风湿性主动脉瓣关闭不全(I35.1)并进行手术治疗的病例87例,检索患者基本信息、主要诊断、主要手术等信息,由心外科主治医师、资深质控医师和编码员组成核查小组,对87份住院病案首页的手术编码等进行质控,同时分析各类手术术式及分类。结果87例病例中行主动脉根部手术:Bentall手术14例,Wheat手术1例;升主动脉及弓部手术:升主动脉置换术2例,Sun's手术18例(包含5例合并Bentall手术,1例合并冠脉搭桥术),支架象鼻术6例;Hybrid杂交手术35例(包含1例合并冠脉搭桥术);微创腔内修复手术11例。其中主要手术错编36例,错误率41.4%,其他手术不同程度错编6例,错误率7%,不同程度漏编71例,漏编率82.8%,不同程度多编13例,多编率14.9%。结论编码员工作中遇到新开展的手术及操作时,需要认真学习相关的解剖学及病生理知识,了解手术操作的术式、入路及具体步骤,合理使用编码规则;医师在开展新技术新手术前应有意识的对编码员进行培训,帮助编码员理解手术步骤及内涵。

Objective The operation code on the first page of the hospitalization record of aortic disease in a cardiac surgery department was analyzed in order to improve the quality of operation code.Methods A total of 87 patients with aortic dissection(I71.0),aortic aneurysm(I71.1-I71.9),aortic root lesion,aortic ulcer(I77.8),non-rheumatic aortic valve stenosis(I35.0)and non-rheumatic aortic valve insufficiency(I35.1)were selected from the first page of cardiac surgery medical records in a third-class hospital in Beijing from September 1,2019 to January 31,2021.The basic information of patients,main diagnosis and major operations were retrieved,and a verification team was formed by cardiac surgery attending physicians,senior quality control physicians and coders to control the operation codes on the first page of 87 hospitalized medical records.At the same time,all kinds of surgical procedures and classification were analyzed.Results Among the 87 cases,aortic root surgery was performed in 14 cases,Wheat operation in one case,ascending aorta and arch operation in 2 cases,Sun's operation in 18 cases(including 5 cases with Bentall operation and one case with coronary artery bypass grafting),stent elephant trunk in 6 cases,Hybrid hybrid operation in 35 cases(including one case with coronary artery bypass grafting)and minimally invasive intracavitary repair in 11 cases.Among them,36 cases were miscompiled in the main surgery,the error rate was 41.4%,6 cases were miscompiled in different degrees in other operations,the error rate was 7%,71 cases were miscompiled in different degrees,the omission rate was 82.8%,and 13 cases were multi-edited in different degrees,with a multi-editing rate of 14.9%.Conclusion When encoders encounter new operations and operations in their work,they need to carefully study the relevant anatomy and pathophysiological knowledge,understand the operative methods,approaches and specific steps of surgical operations,and make rational use of coding rules;doctors should consciously train the coders before carrying out new technologies and new operations to help them understand the surgical procedures and connotation.