摘要
目的:探究提高"经皮冠状动脉支架置入术(PCI)"的编码正确率。方法:将病案首页的数据表细分为5个数据表:基本信息表、诊断信息表、手术信息表、费用信息表、其他信息表。以安徽医科大学第一附属医院心血管内科为试点,针对PCI手术的编码选择不当的问题,在电子病历审核系统中嵌套智能审核PCI手术编码,先设置查询模板再调用,前台显示错误类型,并同时生成审核意见表。结果:智能审核有助于编码人员快速纠正错误编码,能够辅助编码人员进行编码,降低编码过程复杂度。结论:通过对PCI手术编码的智能审核,固化了PCI手术编码规则,大幅度提高了编码的准确率和效率,有助于提高病案首页的数据质量。
Objective: To measure coding accuracy of "percutaneous coronary intervention(PCI)" in the Department of Cardiovascular Medicine. Methods: The data tables on the first page of medical records are subdivided into five data tables, including a table of basic information, a table of diagnostic information, a table of surgical information, a table of fee information and a table of other information. In view that codes are inappropriately chosen for PCI, intelligent review of codes for PCI is nested into the table of surgical information in electronic medical records. At first, templates are set for the review. Then, they are available for searching.Subsequently, wrong types are displayed. At last, a table of review comments is generated. Results: Intelligent review is helpful for coding personnel to rapidly correct wrong codes, assisting in their coding and reducing coding complexity. Conclusion: The intelligent review of codes for PCI standardizes coding for PCI, greatly increases accuracy of coding and makes coding more efficient. It is favorable for improving data on the first page of medical records. Possibility of future intelligent coding is explored as well.
作者
林琳
邢代珍
LIN Lin;XNG Dai-zhen(Department of Information, the First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, P.K.C.)
出处
《中国数字医学》
2019年第2期111-112,共2页
China Digital Medicine
关键词
PCI
手术编码
智能
审核
percutaneous coronary intervention
surgical coding
intelligent
review
