易被忽视的其他手术错误编码案例分析  

Case Analysis of Easily Overlooked Error Coding of Other Operations

作　　者：杜娟[1] Du Juan(Medical Records Department,Beijing Luhe Hospital,Capital Medical University,Beijing 101149,China)

机构地区：[1]首都医科大学附属北京潞河医院病案科,北京市101149

出　　处：《中国病案》2021年第8期44-46,共3页Chinese Medical Record

摘　　要：对日常工作中遇到的其他手术中容易出现错误的编码进行整理,依据手术记录核对手术编码。总结其他手术编码错误的原因包括例如“双轴心分类”、“包括”、“不包括”的编码规则掌握不熟练;对手术操作部位划分不清、对手术目的不明确;编码员对其他手术的编码未给予足够重视。分析编码错误的原因在于编码员对手术编码的理论知识掌握不扎实;对手术内容理解不透彻;对其他手术未给予像主要手术那样重视;编码员的临床知识匮乏制约了对手术的理解程度。编码人员应熟练掌握编码相关专业知识;加强临床知识的学习弥补编码员临床知识不足的缺点;要给予其他手术足够的重视,忽视其他手术会影响整体手术编码的完整性。通过具体案例加以说明其他手术的编码也是不容忽视的。To sort out the wrong codes in other operations encountered in daily work,and check the operation codes according to the operation records.Summarizes the causes of other surgical coding errors,including unskillful mastery of the coding rules of"biaxial classification","including"and"excluding",unclear division of the operation site and unclear purpose of the operation.The coders did not pay enough attention to the coding of other operations.The reason for the analysis of coding errors is that the coders do not have a solid grasp of the theoretical knowledge of surgical coding,do not have a thorough understanding of the contents of the operation,and do not pay as much attention to other operations as the main operations.the lack of clinical knowledge of the coders restricts their understanding of the operation.Coders should be proficient in coding-related professional knowledge;strengthen the study of clinical knowledge to make up for the lack of clinical knowledge;pay enough attention to other operations,ignoring other operations will affect the integrity of the overall surgical code.Through specific cases to illustrate the coding of other operations can not be ignored.

关 键 词：其他手术 ICD-9-CM-3 案例 

分 类 号：R197.323[医药卫生—卫生事业管理]