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目的分析核查某院骨科手术编码情况,提高骨科手术编码的准确性。方法随机抽取某院2015年1月至2016年12月268份进行手术治疗的骨科住院病案,回顾性分析手术操作的编码情况。结果 268份骨科手术病例病案首页手术编码错误6例,错误率2.2%;手术编码遗漏19例,错误率7%;手术名称与手术内容不一致10例,错误率3.7%;手术记录遗漏内容7例,错误率2.6%。结论编码员对疾病分类编码原则掌握不熟练,对临床手术过程不了解,未详细阅读手术记录是造成编码错误的主要原因;临床医师规范手术操作名称书写,提高病历书写质量,加强编码员与临床医师的沟通也是提高编码质量的重要措施。
Objective To analyze and verify the orthopedic surgery coding in a hospital and improve the accuracy of orthopedic surgery coding. Methods A total of 268 orthopedic inpatients admitted to our hospital from January 2015 to December 2016 were selected randomly and the coding of the operation was retrospectively analyzed. Results There were 6 cases (268%) of the 268 cases of orthopedic surgery, the error rate was 2.2%. There were 19 cases missing in the surgical coding, the error rate was 7%. There were 10 cases with inconsistent operation name and operation, the error rate was 3.7% , The error rate of 2.6%. Conclusion Coder is not familiar with disease classification and coding principle, does not understand the clinical operation process, and does not read the surgical records in detail is the main reason of coding errors. Clinicians regulate the writing of surgical operation names, improve the quality of medical records writing, and strengthen the coder and clinical Physician communication is also an important measure to improve coding quality.