摘要
目的调查胆道取石手术操作ICD编码质量情况,正确理解胆道取石的操作部位和不同术式,分析编码错误原因,提高编码质量。方法应用住院病案首页管理系统调取北京某三甲综合性医院2018年1月1日-2018年12月31日诊断为胆囊、胆管结石同时进行胆道结石取出术(不含单纯切除胆囊或肝叶)的病案732份,回顾性分析其手术方式以及ICD编码情况。结果存在编码错误或编码遗漏的病案159例,缺陷率21.72%。总结编码错误的类型,主要体现在解剖部位编错、入路选错和遗漏编码三个方面。分析造成编码错误的原因,主要是编码员没有认真阅读手术操作记录、医师填写住院病案首页手术操作名称不准确以及编码员对字典库和编码原则不熟悉,其中编码员没有认真阅读手术操作记录这个问题最突出。结论胆道结石梗阻的部位、手术入路、操作方式不同,对应的手术编码也各不相同,编码员应该认真阅读病案,对于手术名称或记录书写不规范的病案,应及时与临床医师沟通,避免和减少错误编码。
Objective To investigate the quality of ICD coding in biliary tract extraction operation correctly understand operative locations and different surgical procedures of biliary calculi analyze causes of coding errors and improve coding quality.Methods Using the first page management system of medical records,732 cases diagnosed as gallbladder and bile duct stone removal(excluding cholecystectomy or hepatic lobe)were diagnosed as gallbladder and bile duct stones simultaneously(excluding cholecystectomy or hepatic lobe)from January 1 st 2018 to December 31 st 2018.Results There were 159 cases with coding errors or missing coding errors with defect rate of 21.72%.Summarizing the types of coding errors are mainly reflected in three aspects:incorrect location error path selection and omission coding.The reason for coding errors is mainly because coders do not read surgical records carefully,doctors fill out their first operation names correctly and coders are unfamiliar with dictionary library and coding principles,among which coders do not read surgery record seriously.Conclusion There are different surgical procedures and operative procedures in biliary tract obstruction.Coding officers should read medical records carefully.If they write nonstandard medical records for operation names or records communication should be timely with clinicians avoiding and reducing error codes.
作者
李萌
林海丽
尹思璐
张超
张燕
刘克新
王莹
Li Meng;Lin Haili;Yin Silu;Zhang Chao;Zhang Yan;Liu Kexin;Wang Ying(Medical Record Department of The First Medical Center of PLA General Hospital,Beijing 100853,China)
出处
《中国病案》
2020年第10期45-48,共4页
Chinese Medical Record
关键词
胆结石
取石术
编码
Gallstone
Biliary stone removal surgery
Coding
