摘要
目的通过核查某三甲医院2020年全年眼科视网膜相关手术的编码情况,分析问题并提出改进建议,以提高眼科手术编码的准确率。方法抽取某三甲医院2020年1月1日-2020年12月31日眼科住院病案共2742份,其中视网膜相关手术病案384例,由质控小组对住院病案首页中手术编码情况与手术记录进行逐份核查,对病案中的手术编码漏编和错编情况进行统计,并按照编码缺陷原因进行分类。结果384份视网膜相关手术的眼科病案中,问题病案为26份,其中手术编码漏编7例,漏编率1.82%;错编19例,错编率4.95%。结论通过原因分析,编码员未仔细阅读手术记录与未熟练掌握编码规则、临床医师手术名称书写不规范是住院病案首页手术编码缺陷的主要原因。编码员需熟练掌握ICD-9-CM-3工具书的编码原则,主动与临床医师进行沟通,提高手术操作编码的正确率。
Objectives To improve the accuracy of ophthalmic surgery coding by extracting the coding of ocular retinal surgery cases from a grade hospital,to analyze the problem and put forward suggestions for improvement.Methods 2742 cases were selected from ophthalmology from January 1st,2020 to December 31,2020.A total of 384cases of retinal surgery were screened out.The quality control team checked the code and surgical records one by one,and the final data were statistically analyzed.Results Among 384 cases of retinal surgery,26 cases had problems.Code missed in 7 cases,the error rate was 1.82%,and miscoded in 19 cases,and error rate was 4.95%.Conclusions The reasons for wrong surgery code on the medical records were the coders not reading the operation records carefully and not mastering the coding rules,the non-standard operation name writing of clinicians.Coders should master the coding principles of ICD-9-CM-3 reference books,strengthen the use of reference books,actively communicate with clinicians,improving the accuracy of surgery coding.
作者
徐雯
覃弦
高婧榕
Xu Wen;Qin Xian;Gao Jingrong(Department of Medical Records,The First College of Clinical Medical Science,China Three Gorges University,Yichang Central People’s Hospital,Yichang 443000,Hubei Province,China;不详)
出处
《中国病案》
2022年第12期32-34,共3页
Chinese Medical Record
