日间手术常见疾病及手术编码分析  

Analysis of Common Diseases and Operation Codes for Day Surgery

作　　者：许丹 滕俊玲[1] 刘宁娟[1] 关晓社 蔡青 Xu Dan;Teng Junling;Liu Ningjuan;Guan Xiaoshe;Cai Qing(Medical Records Department, Henan Provincial People＇s Hospital, Zhengzhou 450003, Henan Province, Chin)

机构地区：[1]河南省人民医院病案科,郑州450003

出　　处：《中国病案》2018年第4期33-35,共3页Chinese Medical Record

摘　　要：目的分析某三甲医院一年内日间手术病房收治患者的疾病及手术编码构成情况,并对编码过程中的一些疑难点进行分析讨论。方法采用SPSS17.0软件对2016年6月1日-2017年5月31日期间日间手术病房收治的1810例患者的疾病诊断及手术编码的构成比进行统计描述。结果 1810例患者中普通外科类疾病数量占所有疾病数量的49.78%,为最常见疾病,其次分别为泌尿外科类15.47%、耳鼻喉科类8.12%、乳腺外科类7.90%及整形外科类6.46%疾病;2799例手术中肛门手术例数占所有手术例数的58.84%,为最常见手术,其次分别为体表系统手术16.76%、耳鼻喉手术5.47%、血液和淋巴手术5.22%及泌尿系统手术5.14%。结论编码员应熟悉日间手术病房疾病构成、手术和操作的特点,并掌握常见ICD编码,保证日间病房的编码准确率。Objective To analyze the diseases and operations codes composition of daytime ward at a hospital in one year. Method The SPSS 17.0 was applied for statistical description and by summarizing experience, we discussed some frequently occurred problems. Results Among all the 1810 patients, general surgical patients accounted for 49.78% and are the most occurred; and the next are the urology surgical patients15.47%, ear-nose-throat patients 8.12%, breast surgical patients 7.90% and plastic surgical patients 6.46%. And among all the 2799 operations, anorectal operations accounts for 58.84% and are the most common occurred operations; and the next are the body surface operations 16.76%, ear-nose throat operations 5.47%, blood and lymph operations 5.22% an urinary operations 5.14%. Conclusions Coders in the daytime ward should be well-informed of all the common diseases and operations to ensure the accuracy and quality of coding.

关 键 词：日间病房 手术 编码 

分 类 号：R197.323[医药卫生—卫生事业管理]