摘要
目的通过某院近5年喉癌住院患者的手术数据,对常见手术极易出现的编码错误进行分析,从而提高喉癌手术的编码准确率。方法利用病案统计系统调取2015年1月1日-2019年12月31日所有喉癌并且有手术治疗的住院病案2052份,根据主要手术编码例数进行排序,把最常见的四类手术进行分组,每组随机抽取50份,共计200份住院病案。经过编码质控核查后,找出编码错误的病案,应用描述性统计学的方法分析错误原因。结果调出住院病案中喉病损切除术的百分比最多为55.5%。随机抽取的200份住院病案,核查出48份错误病案,其中编码员与医师易错的原因中,错误率最高的是医师的手术名称的漏填与填错问题分别占比为8%和6%,编码员的临床认知不清占比为5.5%;因为手术操作编码错误的原因中,喉病损切除术与部分喉切除术的错误率最高占到总错误例数的52.1%。结论提高住院病案首页的手术操作编码准确率,需要通过编码员和临床医师共同努力才能完成,编码员既要不断加强ICD专业知识的学习,也要对临床知识有所掌握。临床医师则需要对病案书写规范和住院病案首页的填写原则熟练掌握,还要全院重视后期的继续教育。
Objective Based on the surgical data of inpatients with laryngeal cancer in a hospital in recent 5 years,the coding errors which are easy to occur in common operations are analyzed,so as to improve the coding accuracy of laryngeal cancer surgery.Methods Using the case statistics system to call out all throat cancer from January 1,2015 to December 31,2019 and have surgery medical records,exported to Excel table,according to the number of major surgical coding cases,and then the most common surgery,each group randomly selected 50,a total of 200 medical records,after verification,to find the wrong coded medical records,using statistical methods to analyze the cause of the error.Results A total of 2,052 medical records were transferred,with a maximum percentage of laryngeal surgery being 55.5%.In the 200 randomly transferred medical records,48 error medical records were verified.Among the reasons why coders and doctors are easy to make mistakes,the highest error rate is that the missed and incorrect names of doctors account for 8%and 6%respectively,and the proportion of clinical cognitive confusion of coders is 5.5%.Among the reasons of incorrect coding of surgical operation,the error rate of laryngectomy and partial laryngectomy accounted for 52.1%of the total errors.Conclusion The improvement of the accuracy of surgical operation coding can only be accomplished through the joint efforts of coders and clinicians,coders need to consolidate their own professional knowledge,but also have a grasp of clinical knowledge,clinicians need to write medical records and fill in the home page proficiency,but also need the hospital leadership to pay attention to the later stage of continuing education.
作者
魏巍
李卫红
孙鹏
Wei Wei;Li Weihong;Sun Peng(Medical Record Department,Beijing Tongren Hospital,Capital Medical University,Beijing 100730,China;不详)
出处
《中国病案》
2021年第2期56-58,共3页
Chinese Medical Record
