心血管外科疾病诊断及手术操作编码的情况分析

目的 分析核查我院心血管外科疾病诊断及手术操作编码情况.方法 随机抽查我院2010年1月至2013年12月心外科收治的122份出院病案,回顾性分析病案首页疾病诊断及手术操作的编码情况.结果 疾病诊断方面：主要诊断选择错误6例,错误率为4.9％;疾病编码错误2例,错误率为1.6％;符合Z53编码18例,遗漏率为100％.手术操作方面：手术编码错误8例,错误率为6.5％;手术操作编码漏报12例,错误率为9.8％.结论 做到准确编码,一方面加强临床医师ICD编码知识的培训,医师对疾病诊断和手术操作名称正确、规范书写;一方面编码员必须学习相应专科的医学知识,要养成认真阅读病案的好习惯,积极与临床医师沟通,认真执行ICD编码原则,才能保证编码的准确率.

Situation Analysis on the Diagnosis and Operation Coding of Cardiovascular Surgical Diseases

Objective To analyze and inspect the situation of diagnosis and operation coding of cardiovascular surgical diseases in our hospital.Methods 122 cases of discharged medical records in cardiac surgery department of our hospital from January 2010 to December 2013 were inspected randomly,and conducted a retrospective analysis on the diseases diagnosis and operation coding in home pages of these medical records.Results In aspects of diseases diagnosis,there were 6 cases existing mistakes in the selection of principal diagnosis,the error rate was 4.9％,2 cases existing mistakes in diseases coding,the error rate was 1.6％,18 cases were accordance with Z53 coding,the omitting rate was 100％.In aspects of operation,there were 8 cases existing mistakes in operation coding,the error rate was 6.5％,12 cases failed to report operation coding,the error rate was 9.8％.Conclusions To achieve accurate coding,we should strengthen ICD-10 coding training among clinical doctors so as to manage right and standard diagnosis and operation coding of diseases,and at the same time,coders should study relevant medical knowledge,form the good habit of reading medical records carefully,communicate with doctors positively and implement ICD coding rules carefully,so as to guarantee the accuracy rate of coding.