三种临床手术操作编码错误原因分析  被引量:3

An analysis of the causes of coding errors in three clinical operations

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作  者:张斌[1] 詹湛毅 李小珠[1] 张明玉[1] 陈泽恩[1] 杨法[1] 苏华仁 林洁中[1] ZHANG Bin;ZNAN Zhanyi;LI Xiaozhu;ZHANG Mingyu;CHEN Zeen;YANG Fa;SU Huaren;LIN Jiezhong(Department of Cardiology and Medical Record Room of Zhanjiang Central People’s Hospital,Zhanjiang 524000,China;Zhanjiang School of Traditional Chinese Medicine,Zhanjiang 524000,China)

机构地区:[1]湛江中心人民医院,广东湛江524000 [2]湛江中医学校,广东湛江524000

出  处:《现代医院》2022年第4期570-572,共3页Modern Hospitals

摘  要:在常见的冠名手术、根治术手术和介入放射性手术的临床实践中,应用疾病诊断相关分组(DRGs)与国际疾病分类手术操作(ICD-10-CM-3)书写医疗文件仍然存在的不足之处,阻碍了ICD-10手术操作的规范化和准确化开展。根据实际工作经验,通过分析冠名手术、根治手术和介入放射性应用ICD-10-CM-3编码错误的原因,指出利用统一规范的ICD-10-CM-3编码,可提高分类与书写质量的可行性。建立全国统一标准的ICD-10-CM-3数据库与ICD-10国际疾病,有利于提高ICD-10-CM-3的推广和编码质量及医疗文件书写的提高,对于实现全国医疗共享与服务具有重要的意义。In the clinical practice of common naming surgery,radical surgery and interventional radiation surgery,there are still deficiencies in the application of disease diagnosis related groups(DRGs)and international classification of diseases(ICD-10-CM-3)to write medical documents,which hinders the standardization and accuracy of ICD-10 operation.According to the practical work experience,the causes of wrong coding of ICD-10-CM-3 in naming surgery,radical surgery and interventional radiology were analyzed.The classification and writing quality can be improved by using the unified and standardized ICD-10-CM-3 code.The establishment of a national unified standard ICD-10-CM-3 database and ICD-10 international diseases is conducive to improving the promotion and coding quality of ICD-10-CM-3 and the writing of medical documents.It is of great significance to realize national medical sharing and service.

关 键 词:DRG ICD-9-CM-3 手术编码 冠名手术 根治手术 放射介入手术 

分 类 号:R197.323.1[医药卫生—卫生事业管理]

 

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