先天性巨结肠根治术的编码分析  

Analysis on the Coding of Radical Excision for Hirschsprung’s Disease

作　　者：何治琛 周琴 张文欣[1] He Zhichen;Zhou Qin;Zhang Wenxin(The People's Hospital of Guangxi Zhuang Autonomous Region,Nanning 530021,Guangxi Zhuang Autonomous Region,China;不详)

机构地区：[1]广西壮族自治区人民医院,广西族自治区南宁市530021

出　　处：《中国病案》2020年第12期39-41,共3页Chinese Medical Record

基　　金：广西壮族自治区卫生和计划生育委员会自筹经费科研课题(Z20180714)。

摘　　要：为提高编码人员对3种常见的先天性巨结肠根治术的手术编码的准确性,列举实例和手术步骤并阐述其各自特点,根据ICD-9-CM-3的分类要求对其进行编码:索夫类术式编码48.41,斯温森类术式编码48.49(腹腔镜下为48.42),杜哈梅尔类术式编码48.65。检索某三甲医院2011年1月1日-2019年12月31日行先天性巨结肠根治术的病例,对检索出来的56份住院病案的原手术编码进行校对分析,发现手术名称中未标注术式的手术编码错误率更高。要提高此类手术编码的质量,最重要的是要掌握3种术式的含义及区别,督促临床医师标注术式。编码人员只有不断学习临床知识,仔细阅读手术记录,才能提高手术编码的准确性。To improve the accuracy of operations coding for three commonly kinds of radical excision for Hirschsprung’s disease,enumerate examples and procedures and explain their charactes then encode them according to the classification requirements of ICD-9-CM-3:encoding Sovae procedure in 48.41,encoding Swenson procedure in 48.49(laparoscopic coding is 48.42),encoding Duhamel procedure in 48.65.Retrieving the medical records with radical excision for hirschsprung’s disease of a third-class hospital from January 1 st,2011 to December 31 st,2019,56 cases of the retrieved with primary operations coding was contrastive analyzed.Found that the false rate of the operations coding with operative title unnamed type is higher.To improve the quality of such operations codes,the most important is to clear the meaning and the differences of the three kinds of radical excision,supervise and urge clinicians to write operative title named type.Only by constantly learning clinical knowledge and read the surgical record carefully can coders improve the accuracy of operations coding.

关 键 词：先天性巨结肠根治术 手术编码 索夫 斯温森 杜哈梅尔 

分 类 号：R197.323[医药卫生—卫生事业管理] R726.5[医药卫生—公共卫生与预防医学]