主要手术操作填写与编码准确性分析
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摘要
目的调查病案首页主要手术操作填写与编码的准确性与错误的原因,提高主要手术操作的填写与编码质量。方法采用随机抽样的方法,抽取2016年某三甲医院出院病案中有手术操作病例的2%作为样本,共757份,逐份对照电子病历进行核查。结果主要手术操作填写错误率为4.4%(3.0%~5.8%),主要手术操作编码错误率为8.2%(6.2%~10.1%)。医师的主要错误在于不熟悉ICD-9-CM-3的规则,编码错误的主要原因则在于编码员疏忽和概念不清。结论医师应当加强ICD-9-CM-3知识的学习,编码员要认真查阅手术记录,并加强手术操作编码专业知识和医学知识的学习,以提高主要手术操作填写和编码的准确性。
Objective To investigate the accuracy of filling and coding of principal operations and the cause of wrong codes, so as to improve the quality of filling and coding of principal operations. Methods 757 cases of medical records accounting for 2% of all inpatients with operations in a tertiary hospital in 2016 was selected randomly, and all of them were checked by contrasting to the electronic medical records. Results The error rate of filling ofprincipal operations was 4.4%(3.0%~5.8%), and the error rate of coding of principal operations was 8.2%(6.2% ~ 10.1%). The major mistake of the doctors was being unfamiliar with the regulations of ICD-9-CM-3, and the main reason for coding errors was carelessness and unclear some concepts. Conclusion It should made to strengthen the learning of ICD-9-CM-3 among doctors. The coders should check the operation records carefully, and enhance learning professional knowledge of ICD-9-CM-3 and medical, so as to improve the quality of filling and coding of principal operations.
Objective To investigate the accuracy of filling and coding of principal operations and the cause of wrong codes, so as to improve the quality of filling and coding of principal operations. Methods 757 cases of medical records accounting for 2% of all inpatients with operations in a tertiary hospital in 2016 was selected randomly, and all of them were checked by contrasting to the electronic medical records. Results The error rate of filling ofprincipal operations was 4.4%(3.0%~5.8%), and the error rate of coding of principal operations was 8.2%(6.2% ~ 10.1%). The major mistake of the doctors was being unfamiliar with the regulations of ICD-9-CM-3, and the main reason for coding errors was carelessness and unclear some concepts. Conclusion It should made to strengthen the learning of ICD-9-CM-3 among doctors. The coders should check the operation records carefully, and enhance learning professional knowledge of ICD-9-CM-3 and medical, so as to improve the quality of filling and coding of principal operations.
引文
[1]邓小虹.DRGs在我国的发展应用与推广[J].中华医院管理杂志,2015,31(11):809-812.
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[4]陈俐,尹代红,曾昭宇,等,主要诊断与主要手术操作选择及填写缺陷分析[J],中国病案,2013,14(6):28-29.
[5]刘爱民.国际疾病分类第九版临床修订本ICD-9-CM-32011版[M].北京:人民军医出版社,2014,4.
[2]刘爱民.病案信息学[M].北京,人民卫生出版社,2009:292.
[3]李斌.病案首页中疾病与手术编码存在的问题与分析[J].中国病案,2013,14(6):27-28.
[4]陈俐,尹代红,曾昭宇,等,主要诊断与主要手术操作选择及填写缺陷分析[J],中国病案,2013,14(6):28-29.
[5]刘爱民.国际疾病分类第九版临床修订本ICD-9-CM-32011版[M].北京:人民军医出版社,2014,4.