某院2019年19份冠状动脉旁路移植术病案的编码质控分析

Coding Quality Control Analysis of 19 Cases of Coronary Artery Bypass Grafting in 2019 in a Hospital

目的分析某院2019年1月1日-12月31日冠状动脉旁路移植术的编码质量,查找问题提高该类手术编码的准确性。方法收集2019年某院冠状动脉旁路移植术病案19份,根据《国际疾病分类第九版临床修订本ICD-9-CM-3(2011版)》《住院病案首页数据填写质量规范(暂行)》《住院病案首页数据质量管理与控制指标(2016版)》等标准进行编码质控检查,找出存在的问题以及针对性的改进措施。结果总计检查19份归档病案,其手术及操作编码正确率仅15.79%。其中13份主要手术及操作编码错编,12份因对冠状动脉搭桥数量的掌握不准确而编错,2份主要手术及操作选择错误;15份其他手术及操作编码存在错误,主要错误类型是漏编手术操作附加编码;所有19份病案都遗漏辅助心脏外科手术的体外循环手术操作编码。结论临床医师对主要手术操作选择原则的掌握不准确、手术记录书写错误、编码员知识水平有限以及责任心不强等是造成该类手术编码错误的主要原因。可通过加强相关编码知识培训、开展常态化编码质控、建立有效医师编码员沟通机制提高编码的正确性。

Objective The coding quality of coronary artery bypass grafting(CABG)performed in a hospital from January 1st to December 31st,2019 was analyzed to find problems to improve the accuracy of such surgical coding.Methods A total of 19 medical records of coronary artery bypass grafting in a hospital in 2019 were collected.According to the International Classification of Diseases 9th edition Clinical Revision-3(2011 edition),Quality Specifications for Data Fillings in the Front Page of Medical Records(Interim),Quality Management and Control Indicators for Data Fillings in the Front Page of Medical Records(2016 edition)and other standards,the coding quality control was checked,then found out the existing problems and targeted improvement measures.Results A total of 19 archived medical records were examined,and the correct rate of operation and coding was only 15.79%.Among them,the main operation and operation codes of 13 archived medical records were miscoded,12 archived medical records were miscoded due to the inaccurate understanding of the number of coronary artery bypass grafts,and 2 archived medical records were wrongly selected for the main operation and operation.There were errors in the coding of other operations and operations in 15 medical records.The main type of errors was omission of additional coding of surgical operations.All 19 cases omitted the code for extracorporeal circulation as an adjunct to cardiac surgery.Conclusions The inaccuracy of clinicians in selecting principles of major surgical procedures,the wrong writing of surgical records,the limited knowledge of coders and the poor sense of responsibility were the main reasons for the coding errors of this kind of surgery.The correctness of coding could be improved by strengthening the training of relevant coding knowledge,carrying out normal coding quality control and establishing an effective communication mechanism among physician coders.