摘要
目的分析心脏外科住院患者情况,提高Z53编码使用准确率。方法根据《国际疾病分类第十次修订本(ICD-10)BJ-临床版》分类原则,筛查分析某医院心脏外科住院但未进行手术操作的患者情况。结果 Z53编码的正确使用取决于医师的详细书写的病历资料,以及编码员正确编码两方面因素。通过提高对Z53编码的认识,Z53编码使用正确率从2011年的零,增加到2013年的76%。结论规范临床医师正确书写出院诊断及详细书写病程记录,加强编码员与临床医师的沟通,提高编码员对Z53编码的认识,确保Z53编码在心外科疾病分类的准确使用。
Objective To analyze hospitalized patients of cardiac surgery, and increased accuracy of Z53. Methods Analyzing car- diac surgery patients without surgery according to principle of classification of ICD-10 （BJ-clinical version）. Results The proper usage of Z53 depends on the physician detailed written records and coders correctly ceding. Z53 coding using accuracy from zero in 2011, increased to 76% in 2013 by raising awareness of Z53 coding. Conclusion We should standardize clinician correctly written discharge diagnosis and progress note, strengthen communication between coders and clinicians, improve the recognition of Z53 to ensure the accurate use of Z53 coding in cardiac surgery patients.
出处
《中国病案》
2013年第11期41-42,共2页
Chinese Medical Record
关键词
心脏外科
手术操作
疾病编码
Z53
Cardiac surgery
Surgical operation
Disease coding
Z53
