骨科手术ICD编码主要缺陷与原因分析

目的分析骨科手术ICD编码主要缺陷与原因,促进骨科手术编码准确度提升。方法回顾性分析该院在2018年1月-2019年7月所收治的536份骨科患者住院病案,由2名编码员来分析骨科手术ICD编码主要缺陷及发生原因。结果 536例骨科手术ICD编码缺陷发生率7.46%(40/536),是以编码遗漏、编码错误、手术记录信息遗漏、手术名称与信息不符为主。缺陷原因结果显示脱离工具书、编码原则尚未掌握、尚未仔细阅读病历、手术操作名称书写不规范为主要原因。结论骨科手术ICD编码缺陷发生主要是以编码信息遗漏、错误为主,之所以会出现这一现象关键还是在于编码人员对疾病分类掌握程度不够,亦或者是临床手术中未详细阅读手术记录等。

Analysis of the Main Defects and Causes of ICD Codes in Orthopedic Surgery

Objective To analyze the main defects and causes of ICD codes in orthopedic surgery, and to improve the accuracy of orthopedic surgery codes. Methods A retrospective analysis of 536 orthopedic patients admitted to our hospital from January 2018 to July 2019. Two coders were used to analyze the main defects and causes of ICD codes in orthopedic surgery. Results The incidence of ICD coding defects in 536 cases of orthopedic surgery was 7.46%(40/536), which was mainly due to missing codes, incorrect coding, missing information in the operation records, and inconsistent operation names and information. The results of the defect cause showed that the main reasons were the departure from the reference book, the coding principles have not been mastered, the medical records have not been read carefully, and the surgical operation names are not standardized. Conclusion ICD coding defects in orthopedic surgery are mainly caused by missing or incorrect coding information. The key reason for this phenomenon is that the coding staff does not have sufficient knowledge of disease classification, or the surgical records have not been read in detail during clinical operations.