摘要
目的统计血液科住院病案首页常见操作编码情况,找出错误编码原因,寻求解决对策。方法提取某三甲综合医院2018年1月1日-2018年12月31日血液科实施操作的住院病案,逐一查阅相关内容,核对操作编码准确性。结果 673份住院病案中,存在编码缺陷的401份,缺陷率为59.58%。其中,骨髓穿刺术错编为供者骨髓抽吸,为了移植的占62.84%;骨髓穿刺术错编为骨髓活检术的占20.20%;鞘内注射化疗药物错编为注射或输注其他治疗性或预防性药物的占11.72%;漏编骨髓穿刺术的占5.24%。结论编码工作者在日常工作中应严格遵循编码规则及步骤进行手术操作分类编码,熟知相关临床专科知识,同时规范临床医师手术操作名称的书写,确保编码数据的真实可靠。
Objective Conclude the common operation coding condition of the Front pages of hospitalization cases in the hematology department,find out the reasons for error coding and figure out the corresponding solutions.Methods Extract medical records of the operation performed in the hematology department of xx hospital(a 3 rd degree and grade A general hospital) from 1 January 2018 to 31 December 2018,and then check relevant content in the records one by one and verify the accuracy of the operation coding.Results Among 673 records,there are 401 records that have coding deficiency,the rate of deficiency is 59.58 percent.Among them,bone marrow puncture mis-edited to donor bone marrow suction,for transplantation accounted for 62.84 percent,bone marrow puncture mis-edited to bone marrow biopsy accounted for 20.20 percent,intra-injection chemotherapy drugs mis-edped into injection or infusion of other therapeutic or preventive drugs accounted for 11.72 percent,missing bone marrow puncture 5.24 percent.Conclusion Coding workers in the daily work should strictly follow the coding rules and procedures for surgical operation classification coding,familiar with the relevant clinical expertise,while normative operation name writing for clinician,to ensure the true and reliable coding data.
作者
侯丽
程红群
Hou Li;Cheng Hongqun(Department of Medical Records,The 8th Medical Center Of Chinese PLA Center Hospital,Beijing 100091,China)
出处
《中国病案》
2019年第10期37-39,共3页
Chinese Medical Record
关键词
血液科
操作
编码
分析
Hematology
Operation
Coding
Analysis
