摘要
目的为分析基于病病诊断相关分组(DRGs)分组付费原理分析乳腺癌手术操作编码的错误案例以减少手术操作编码错误的情况。方法本研究在2019年7月至2023年7月期间于在我院接受乳腺癌手术治疗的患者为研究对象,基于DRGs分组原理收集了乳腺癌手术治疗的患者380例,并对这些患者的病案数据进行核查,收集核查结果包括不同手术方式以及不同分期患者中错误编码的发生率情况、错误编码的类别分布以及错误编码的责任人情况。结果通过对380例患者的病案数据核查,发现其中有错误编码案例44例,不同手术方式以及不同分期患者中错误编码的发生率情况差异无统计学意义(χ^(2)=2.504,P>0.05),编码不完整错误有5例,编码不准确有17例、编码不规范有18例、编码不一致有4例,分别占错误编码的比例11.4%、38.6%、40.9%以及9.1%;临床医师发生错误编码情况有39例占总错误的比例为88.6%、编码员发生错误情况有5例占总错误的比例为11.4%。结论我院编码错误类型主要是编码不准确以及编码不规范的问题,并且临床医师发生错误编码情况较多。
Objective Analyze the error cases of breast cancer surgical operation coding based on DRGs grouping principle to reduce the eror of surgical operation coding.Methods In this study,380 patients with breast cancer undergoing surgical treatment in our hospital from July 2019 to July 2023 were collected based on the DRGs grouping principle.The medical record data of these patients were checked.The collection and verification results included the occurrence rate of error codes in patients with different surgical methods and different stages,the category distribution of error codes,and the person responsible for error codes.Results Through the verification of medical record data from 380 patients,it was found that there were 44 cases of incorrect coding,and there was no significant dfference in the incidence of incorrect coding among patients with different surgical methods and stages(χ^(2)=2.504,P>0.05),there were 5 cases of incomplete coding errors,17 cases of inaccurate coding,18 cases of non-standard coding,and 4 cases of inconsistent coding,accounting for 11.4%,38.6%,40.9%,and 9.1%of incorrect coding,respectively.There were 39 cases of coding errors among clinical physicians,accounting for 88.6%of the total errors,and 5 cases of coding errors among coders,accounting for 11.4%of the total errors.Conclusion The main types of coding errors in our hospital are inaccurate and nonstandard coding,and there are many cases of coding errors among clinical physicians.
作者
余艳
蔡庆婷
黄云
刘体娟
王娜娜
徐洪斌
Yu Yan;Cai Qingting;Huang Yun;Liu Tjuan;Wang Nana;Xu Hongbin(Department of Medical Records,Anshun People's Hospital,Anshun 561000,China)
出处
《实用医技杂志》
2024年第3期215-218,共4页
Journal of Practical Medical Techniques
