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目的提高心血管外科操作编码的准确性。方法利用病案数字化综合管理系统进行检索,随机抽取某三甲综合医院2014年1月至2015年12月心血管外科259份出院病案,回顾性分析心外科住院病案首页操作的编码情况。结果编码遗漏62例,错误率25.86%;编码错误3例,错误率1.16%;操作书写不规范12例,错误率4.63%。结论操作编码水平的提高,要从加强临床医师ICD编码知识的培训,规范操作名称书写;加强编码员对临床知识的学习,养成认真阅读病案的好习惯;建立科室病案质控管理,保障病案书写质量;加强编码员与临床医师的沟通等,认真执行ICD-9-CM-3编码原则,才能保证操作编码准确率。
Objective To improve the accuracy of cardiovascular surgery coding. Methods A total of 259 cases of discharged patients in a department of general surgery hospital from January 2014 to December 2015 in cardiovascular surgery were randomly selected by using the medical record digital comprehensive management system. The coding of the first page of cardiology operation in hospital was retrospectively analyzed. Results 62 cases were missed by coding, the error rate was 25.86%. Three cases were coded incorrectly, the error rate was 1.16%. The operation was not standardized in 12 cases, the error rate was 4.63%. Conclusion To improve the coding level of operation, it is necessary to strengthen the training of clinician ICD coding knowledge, standardize the operation name writing, enhance the coder’s learning of clinical knowledge and develop a good habit of carefully reading the medical record. Establish quality control management of medical records and ensure the medical record Writing quality; strengthen the coder and clinician communication, etc., and earnestly implement the ICD-9-CM-3 coding principle, in order to ensure the accuracy of the operation coding.