摘要
目的通过回顾某院出院病案手术术式,分析易错手术操作编码,提高手术操作编码质量。方法检索2023年1月1日—2023年12月31日出院病案的主要手术,确定带蒂皮瓣移植术、缺血性脑血管病介入治疗、脑动脉瘤血管内栓塞术、甲状腺癌手术、乳腺癌手术、脊柱融合术、人工流产术共7类手术为易错手术操作编码,共计894例,组建院级病案编码质控小组进行回顾性质控。结果894例病案中,存在编码缺陷的384例,总错误率为42.95%。其中,手术操作编码错误249例、手术操作编码漏编128例、手术操作编码多编10例。结论易错手术操作编码错误率较高,与临床医师填写不规范、编码人员知识储备不足有关,应规范病历书写,提升编码人员业务能力,加强编码培训与业务交流,多举措提升手术编码质量。
Objectives This study aims to review the surgical procedures in the discharge medical records of a certain hospital,analyze the error-prone surgical operation codes,and improve the quality of surgical operation coding.Methods The main surgical procedures of the medical records discharged from the hospital from January 1 to December 31,2023 were searched,and seven types of operations were identified,including pedicled skin flap transplantation,interventional treatment of ischemic cerebrovascular disease,intravascular embolization of cerebral aneurysms,thyroid cancer surgery,breast cancer surgery,spinal fusion,and induced abortion.A total of 894 cases were included,and a hospital-level medical record coding quality control team was established to conduct retrospective quality control.Results Out of 894 cases,384 exhibited coding defects,resulting in an overall error rate of 42.95%.Specifically,there were 249 cases with incorrect surgical procedure codes,128 cases with missing surgical procedure codes,and 10 cases with multiple codes.Conclusions The high error rate in frequently erroneous surgical procedure codes is linked to issues such as non-standard clinical documentation and insufficient knowledge among coding personnel.To improve coding quality,it is essential to standardize clinical documentation practices,enhance the business capabilities of coders,and strengthen coding training and professional communication.Implementing these measures will contribute to better surgical coding accuracy.
作者
高雪梅
秦晓华
Gao Xuemei;Qin Xiaohua(Jinan Fourth People's Hospital,Jinan City 250031,Shandong Province,China;不详)
出处
《中国病案》
2025年第5期23-26,共4页
Chinese Medical Record
