52例脊柱结核及其并发症诊断与手术编码质量缺陷分析

Analysis on Diagnosis and Coding Defects of Spinal Tuberculosis and Its Complications in 52 cases

目的通过对某院病案首页中脊柱结核及其并发症诊断与手术操作编码缺陷原因进行分析,为提高疾病诊断及手术编码的准确率提供参考依据。方法从病案信息系统调取2019年5月1日-2020年4月30日进行手术治疗的脊柱结核及其并发症病案52例,回顾性分析疾病诊断和手术编码缺陷情况。结果52例病案首页疾病诊断及手术编码总缺陷频次为94次。临床医师原因造成的缺陷频次49次,占比52.13%,其中主要诊断错误8次,占比16.33%,漏诊并发症20次,占比40.82%,漏填椎管减压术21次,占比42.85%;编码员原因造成的缺陷频次45次,占比47.87%。选择主要手术及入路编码错误29次,占比64.45%,漏编、错编其他手术16次,占比35.55%。结论病案首页和编码仍存在诸多不足,需加强对临床医师、编码员专业知识的培训和考核,增强其责任心,相互配合,并建立有效质量控制体系,以达到稳步提升脊柱结核病案首页中诊断和手术编码的正确性。

Objectives Based on the front page of the hospital’s medical records, analyzed and described the causes of defects of spinal tuberculosis and the diagnosis of its complications, with the defects of surgical coding, so as to improve the accuracy of the diagnosis and surgical coding. Methods 52 cases of spinal tuberculosis undergoing surgical treatment from May 1 st, 2019 to 30 th, April 2020 were collected from the medical record system. The disease diagnosis and surgical coding defects were analyzed retrospectively. Results There were total 94 defects of diagnosis and surgical coding among 52 cases in the front page of medical records. The defects caused by clinicians were 49 cases, accounting for 52.13%, of which 8 cases were diagnosed incorrectly, accounting for 16.33%, 20 cases of missed diagnosis of complications, accounting for 40.82%, and 21 cases of missing spinal canal decompression, accounting for 42.85%;the defects caused by coders were 45 cases, accounting for 47.87%.There were 29 cases of wrong selection of main surgery coding and approach coding, accounting for 64.45%, and 16 cases of missing or wrong coding of other operations, accounting for 35.55%. Conclusions There were still many deficiencies in the front page of the medical record and the coders. It was necessary to strengthen the training and assessment of the professional knowledge of clinicians and coders, enhance their sense of responsibility, cooperate with each other, and establish an effective quality control system, so as to steadily improve the accuracy of diagnosis and surgical coding in the front page of spinal tuberculosis cases.