心脏起搏器置入术编码分析  

Discussion on Coding of Cardiac Pacemaker Device

作　　者：马靖 武霞霞 张晓东 卫阳阳 孙琦婷 岳爱琴 郭楠 常文娟 Ma Jing;Wu Xiaxia;Zhang Xiaodong;Wei Yangyang;Sun Qiting;Yue Aiqin;Guo Nan;Chang Wenjuan(Department of Medical Record Statistics,Shanxi Cardiovascular Hospital,Taiyuan 030024,Shanxi Province,China;不详)

机构地区：[1]山西省心血管病医院病案统计科,山西省太原市030024 [2]山西省心血管病医院核医学科,山西省太原市030024 [3]山西医科大学第一医院呼吸与危重症医学科,山西省太原市030001

出　　处：《中国病案》2021年第11期49-50,112,共3页Chinese Medical Record

基　　金：山西省研究生教育创新项目(2019BY084)。

摘　　要：目的通过对心脏起搏器手术编码的探讨,提高起搏器手术编码正确率。方法检索某院2020年1月1日-2020年12月31日行起搏器手术的926份病案,依据《国际疾病分类第九版临床修订本手术与操作2011版》的分类要求,通过阅读原始病案,核查每1份病案编码,分析主要问题和编码错误的类型:结果编码主要错误中导线漏编错编占第1位(92.55%),其次为起搏器类型编码错误(71.17%)、脉冲发射器与全系统置入编码混淆(33.69%)、起搏器的置入与置换编码错误(9.61%)。结论起搏器置入术编码错误较多,编码中应注意耗材表、标签贴单等信息,关注起搏器类型及导线情况,通过精准编码,提高编码准确率。Objectives By improving the coding level of artificial pacemaker,we can precisely encode pacemaker surgery,and improve the data utilization rate by retrieving difficult cases and new technology cases.Methods To learn the coding of pacemaker implantation,926 pacemaker operation records in 2020 were re-coded by reading the original medical records,surgical records,consumable table and consumable label list,use PARETO analysis to identify major problems and analyze the causes of coding errors.Results The main causes of coding errors are miscoding and coding errors of special leads codes(left ventricular leads,defibrillation leads,pacemaker without leads,temporary pacemaker).Coding on pacemaker types and confusion between pulse generator and whole system implantation are the other main reasons which lead to coding errors.Conclusions The coding of pacemaker implantation should pay attention to the information of consumable table and label.More attention should be paid to the type of pacemaker and the condition of pacemaker leads.Accurate encoding could improve the accuracy of encoding and the utilization rate of data.

关 键 词：心脏起搏器 ICD编码 导线 

分 类 号：R654.2[医药卫生—外科学] R197.323[医药卫生—临床医学]