肠造口术在ICD-9-CM-3手术操作分类中的编码分析  

Coding Analysis of Enterostomy in the Classification of ICD-9-CM-3

作　　者：向思京 Xiang Sijing(Beijing Shijitan Hospital Affiliated to Capital Medical University,Beijing 100038,China)

机构地区：[1]首都医科大学附属北京世纪坛医院,北京市100038

出　　处：《中国病案》2020年第12期41-43,共3页Chinese Medical Record

摘　　要：目的通过分析肠造口术在ICD-9-CM-3手术操作分类中编码常见错误及原因,提高肠造口术编码的准确性。方法利用住院病案首页信息系统检索某院2017年1月1日-2018年12月31日空肠、回肠、结肠造口手术住院病案505份,由资深编码员3名和结直肠科主治医师2名组成质控小组,对505份住院病案首页中手术操作进行质控,汇总缺陷问题。结果进行肠造口手术的505份住院病案中126份住院病案首页中存在手术编码缺陷,其中手术多编码38份,错误率30.2%;手术编码错编54份,错误率42.9%;漏编手术编码34份,错误率26.9%;手术编码准确率为76%。错误原因以编码员临床知识不足导致编码错误最多,45例,占错误的35.7%,其次为临床医师填报有误导致编码错误44例和编码原编码规则掌握错误37例。结论编码员对编码规则掌握不全面、临床知识储备不足,临床医师病历书写不规范等是导致肠造口手术编码错误的主要原因,加强编码员临床知识学习和临床医师手术操作填写规则培训是避免错误的重要途径。Objective To improve the accuracy of enterostomy coding, the common errors and causes of enterostomy coding in ICD-9-CM-3 were analyzed. Methods A total of 505 hospitalized medical records of jejunum, ileum and colostomy in a hospital from January 1, 2017 to December 31, 2018 were searched by the information system of the first page of hospital medical records. The quality control group was composed of 3 senior coders and 2 attending colorectal physicians. Quality control was carried out on the first page of 505 hospitalized medical records, and defects were summarized. Results Of the 505 hospitalized medical records that underwent enterostomy, 126 had surgical coding defects on the first page, including 38 surgical codes, with an error rate of 30.2%;54 surgical codes were miscoded, with an error rate of 42.9%;34 surgical codes were omitted, with an error rate of 26.9%;the accuracy of surgical coding was 76%. The causes of errors were coding errors caused by lack of clinical knowledge of coders, 45 cases, accounting for 35.7% of the errors, followed by 44 cases of coding errors caused by errors reported by clinicians and 37 cases of errors in mastering the original coding rules. Conclusion The main causes of coding errors in enterostomy are the lack of comprehensive mastery of coding rules, insufficient reserve of clinical knowledge and non-standard writing of medical records of clinicians. Strengthening the learning of clinical knowledge of coders and the training of clinicians to fill in rules for surgical operation is an important way to avoid errors.

关 键 词：肠造口 编码分析 ICD-9-CM-3 

分 类 号：R197.323[医药卫生—卫生事业管理]