摘要
目的 通过分析侵入性神经调控术疾病及手术编码错误原因,探讨不同类型神经调控术的诊断编码及手术编码,提高编码的准确率。方法 检索某三甲医院2020年1月1日-2024年6月31日出院病案中主要手术为侵入性神经调控术住院病案首页。其中符合条件的病案共655份。检查主要诊断及主要手术编码的准确性,并对编码错误原因进行分析。结果 655份病案中,主要诊断错误编码为22例,错误率3.35%,其中,难治性癫痫错编率最高,占比2.29%;主要手术编码错误例数111例,主要手术编码错误率为16.95%;附加编码错误例数为211例,附加编码错误率为32.21%。通过分析发现错编的主要原因为编码员对相关疾病及手术的编码知识掌握欠缺,未仔细查阅编码工具书;其次为编码员缺乏相关临床知识,未明确手术原理;再次为临床医师手术记录未明确植入物类型,编码员无法判断。结论 侵入性神经调控术疾病及手术编码错误率较高,作为编码员应该不断学习,了解新医疗、新技术,加强与临床沟通,才能更好完成编码工作。
Objectives To analyze the causes of invasive neuroregulatory diseases and surgical coding errors,to explore the diagnostic coding and surgical coding of different types of neuroregulatory procedures,and improve the accuracy of coding.Methods From January 1st,2020 to June 31st,2024,the inpatient records of a Three A and Tertiary Hospital were searched for the front page of the inpatient records of doctors whose main operations were invasive neuromodulation.A total of 655 cases were eligible.Check the accuracy of major diagnosis and major surgical coding,and analyze the causes of coding errors.Results Among the 655 cases,there were 22 cases with the error rate of 3.35%.Among them,refractory epilepsy had the highest error rate,accounting for 2.29%.The number of major surgical coding errors was 111,with a major surgical coding error rate of 16.95%.The number of additional coding errors was 211,and the error rate of additional coding errors was 32.21%.Through analysis,it was found that the main reason of miscoding was that coders lack the coding knowledge of related diseases and operations,and did not carefully consult the coding reference books;Secondly,the coders lacked relevant clinical knowledge and did not make clear the operation principle.Again,the surgical record for the clinician did not specify the implant type,which the coder could not determine,resulting in missing complete.Conclusions The coding error rate of invasive neuroregulatory diseases and surgical procedures was high.Coders should keep learning to understand new medical treatment and new technology in order to complete the coding work better.
作者
张欣欣
李汶嘉
苟瑜坤
孔德莹
张文
张阳华
许莹
Zhang Xinxin;Li Wenjia;Gou Yukun;Kong Deying;Zhang Wen;Zhang Yanghua;Xu Ying(Department of Medical Information Management,The First Affiliated Hospital of Xi'an Jiaotong University,Xi'an 710061,Shanxi Province,China;不详)
出处
《中国病案》
2025年第2期43-46,共4页
Chinese Medical Record
基金
国家卫健委卫生健康统计工作高质量发展揭榜攻关项目
陕西省自然科学基础研究计划青年项目(S2024-JC-QN-0995)
院科研发展基金(2022RKX-08)。
