摘要
本文利用某院住院病案首页信息查询系统,对2019年1月-6月心内科有介入操作的出院病案进行检索,并重新核查,总结常见的编码错误,从而提升住院病案首页编码的正确率。主要从心脏起搏器置入37.8、术中心脏电生理检查37.26、分叉血管的操作00.44,这三类编码问题进行阐述,分析编码员编码错误的原因,并提出对应的解决措施。通过对心内科错误编码的分析,编码员临床知识相对欠缺,日常工作中过于依赖电子字典库,缺少经常查询工具书的习惯。此外,还应该建立病案科与临床科室的沟通机制,从而提高住院病案首页的编码质量。
This article using a hospital’s medical record home page information query system,search for a medical record of a hospital with an interventional operation in the Department of Cardiology from January to June 2019 and recheck,summarize common coding errors,improve the accuracy of coding on the front page of medical records.Mainly implanted from a pacemaker 37.8,Intraoperative cardiac electrophysiological examination 37.26,Procedure on vessel bifurcation 00.44,These three types of coding problems are elaborated,analyze the reason for coding staff coding errors,and propose corresponding solutions.Based on the analysis of cardiology error coding,the lack of clinical knowledge of coding staffs,rely too much on electronic dictionary in daily work,lack of the habit of frequently querying reference books.In addition,establishing communication mechanism between medical record department and clinical department,thereby improving the coding quality of first page of medical record.
作者
刘天野
刘辰龙
Liu Tianye;Liu Chenlong(Peking University First Hospital,Beijing100034,China)
出处
《中国病案》
2020年第2期30-33,共4页
Chinese Medical Record
关键词
ICD
操作编码
心内科
ICD
Operational coding
Cardiology
