下肢动脉粥样硬化性闭塞症的手术编码错误案例分析  

Analysis of Surgical Coding Errors in Atherosclerotic Occlusive Disease of Lower Extremities

作　　者：王玥[1] 董爱然[1] 张丽[1] 吕方[1] 韩金梦 张潇 Wang Yue;Dong Airan;Zhang Li;Lv Fang;Han Jinmeng;Zhang Xiao(Xuanwu Hospital Capital Medical University,Beijing 100053,China;不详)

机构地区：[1]首都医科大学宣武医院,北京市100053

出　　处：《中国病案》2020年第12期34-36,共3页Chinese Medical Record

摘　　要：随机抽取某医院2019年1月1日-2019年12月31日主要诊断为下肢动脉粥样硬化性闭塞症且进行手术操作的住院病案,重新审核其下肢动脉粥样硬化闭塞症的手术编码情况,以典型案例概括出编码中出现的4类错误类型:主要手术操作选择错误、遗漏其他手术操作、多编其他手术、医师手术记录不准确。通过典型案例归纳总结常见编码错误,分析导致编码错误原因,总结改进方法,加强编码员的手术分类专业知识的学习,加强对临床医师病历书写的培训,建立完善的编码质控流程,以提高下肢动脉粥样硬化闭塞症手术编码的准确性,进而提高手术编码质量。From January 1, 2019 to December 31, 2019, the hospitalized medical records of atherosclerotic occlusive disease of lower extremities were randomly selected, and the surgical codes of atherosclerotic occlusive disease of lower extremities were re-examined. Four types of errors in coding were summarized with typical cases: incorrect selection of main surgical procedures, omission of other surgical procedures, multi-editing of other operations, and inaccurate surgical records of doctors. Through typical cases, we summarize the common coding errors, analyze the causes of coding errors, summarize the improved methods, strengthen the study of the professional knowledge of surgical classification of coders, and strengthen the training of clinicians in writing medical records, establish a perfect coding quality control process to improve the accuracy of surgical coding for atherosclerotic occlusive disease of lower extremities, and then improve the quality of surgical coding.

关 键 词：下肢动脉粥样硬化性闭塞症 ICD-9-CM-3 案例 

分 类 号：R197.323[医药卫生—卫生事业管理]