摘要
目的通过分析呼吸病介入中心住院病案首页,探讨ICD-9-CM-3手术编码疑点和易错点,提高编码的正确率。方法从病案系统检索某三甲专科医院2021年1月1日至2021年12月31日从呼吸病介入中心出院的1365份病案,筛选呼吸内镜入路的手术操作编码共1671条。根据编码细目进行分层抽样,质控核查编码问题,分析原因。结果呼吸介入手术或治疗性操作占比不高,但是编码分布范围广。抽查的290条编码中,医师填写错误共185条,编码员审核质控后编码错误148条,主要的错误内容是手术操作的解剖部位错误和内镜检查、活组织检查、内镜下治疗混淆不清。结论医师和编码员对呼吸介入手术操作编码的填写不够重视,编码员对呼吸介入手术操作相关临床知识欠缺,应开展医师和编码员的相关培训,加强医师与编码员的有效沟通,提高编码员的专业素养,从而提高手术操作编码的准确性。
Objectives By analyzing the front page of the medical records discharged from the respiratory intervention center,the error-prone points of ICD-9-CM-3 coding were explored,so as to improve the accuracy of coding.Methods Using the medical record system to call out all the medical records discharged from the respiratory intervention center of a tertiary specialized hospital from January 1st,2021 to December 31st,2021.1365 cases were retrieved and 1671 codes were screened.Stratified sampling was carried out according to the coding details,and quality control was done to analyze the cause of the error.Results The proportion of surgery or therapeutic operation in respiratory intervention center was not high,but the coding distribution range was large.Among the 290 codes checked,the doctors filled in 185 coding errors,and the coder made 148 coding errors.The main error contents were the anatomical error of the surgical operation and the confusion of endoscopy,biopsy and endoscopic treatment.Conclusions Doctors and coders didn’t pay enough attention to the respiratory endoscopic operation coding,and coders lacked clinical knowledge of the respiratory intervention surgery.Relevant training of doctors and coders should be carried out to strengthen the effective communication and improve the professional quality of coders,so as to improve the accuracy of surgical operation coding.
作者
刘媛
汪刚
Liu Yuan;Wang Gang(Statistical Center of Shanghai Chest Hospital,Shanghai Jiao Tong University School of Medicine,Shanghai 200030,China;不详)
出处
《中国病案》
2023年第8期37-40,共4页
Chinese Medical Record
