乳腺癌手术编码的错误案例分析  

Error Cases Study of in Breast Cancer Surgical Coding

作　　者：贺梦宇 张丽[1] 吕方[1] 王玥[1] He Mengyu;Zhang Li;Lv Fang;Wang Yue(Xuanwu Hospital of Capital Medical University,Beijing 100053,China;不详)

机构地区：[1]首都医科大学宣武医院,北京市100053

出　　处：《中国病案》2022年第5期16-18,共3页Chinese Medical Record

摘　　要：检索某医院2020年1月1日-2020年12月31日的143份乳腺癌手术病案,重新审核每份病案的手术编码情况,归纳出主要手术错编码、其他手术多编码、其他手术漏编码、主要手术编码选择错误4种错误类型,分析这4种乳腺癌手术编码的典型错误案例。通过总结各案例手术编码的错误原因提出了加强编码员知识和素质的培养、建立与临床医师的沟通渠道、优化编码质控模式等改进方法。通过优化乳腺癌手术的编码质量,梳理乳腺癌手术编码的难点和混淆点,提高乳腺癌手术编码的正确率,降低由于编码员手术编码错误的原因而造成乳腺癌病例DRGs入组错误的情况。The retrieval of a hospital on January 1st,2020,2020 to December 31st,143 breast cancer surgery medical record,review each of the medical record coding operation,summed up the main surgery wrong coding,coding and other surgery other leakage coding,selection of surgery coding errors,analysis of the above four kinds of coding the typical fault cases of breast cancer surgery.By summarizing the reasons of the errors of surgical coding in each case,some improvement methods were put forward,such as strengthening the training of coders’ knowledge and quality,establishing communication channels with clinicians,and optimizing the quality control mode of coding.By optimizing the coding quality of breast cancer surgery,sorting out the difficulties and confusion points of breast cancer surgery coding,improving the accuracy of breast cancer surgery coding and reducing the DRGs inclusion errors of breast cancer cases caused by coders’ surgical coding errors.

关 键 词：乳腺癌 ICD-9-CM-3 手术编码 编码质量 DRGS 

分 类 号：R197.323[医药卫生—卫生事业管理] R737.9[医药卫生—公共卫生与预防医学]