眼科同临床手术名称不同编码的情况分析  

Coding Analysis of the Ophthalmic Clinical Operations with the Same Surgical Names

作　　者：柯乃绮 容莹 林明色[1] 方浩[1] Ke Naiqi;Rong Ying;Lin Mingse;Fang Hao(State Key Laboratory of Ophthalmology,Zhongshan Ophthalmic Center,Sun Yat-sen University,Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science,Guangzhou 510060,Guangdong Province,China.;不详)

机构地区：[1]中山大学中山眼科中心,眼科学国家重点实验室,广东省眼科视觉科学重点实验室,广东省广州市510060

出　　处：《中国病案》2023年第9期48-50,共3页Chinese Medical Record

摘　　要：对住院病案首页进行编码的过程中存在不少同临床手术名称不同编码的情况。这是编码易错点和难点,直接影响住院病案首页数据质量。手术操作名称的各个组成成分均有可能影响编码。眼科手术和其他章分类最不同之处在于疾病性质、手术目的、手术伴随情况等都有可能影响编码分类,对编码的准确性起着关键的作用。通过梳理了眼科编码特点,对比与探讨眼科常见的同临床手术名称不同编码的术式,总结编码思路。分析发现导致编码易错的主要原因是编码员忽略查找编码工具书;临床医师书写病历欠详细等。建议编码员在索引中仔细查找编码,临床医师详尽准确书写病历,共同提高眼科编码准确性。In the process of coding the front page of inpatient medical records,there are many situations where the same clinical operation name is coded differently.This is the error-prone and difficult point of coding,which directly affects the data quality of the front page of inpatient medical records.The difference between ophthalmic surgery and other chapter classifications is that the nature of the disease,the purpose of the operation,and the accompanying conditions of surgery may affect the coding classification and play a key role in the accuracy of coding.This paper reviews the characteristics of ophthalmic coding,compares,and discusses the common ophthalmic surgery methods with different coding names of clinical surgery,and provides coding ideas.The main reasons for coding errors include the coders ignore searching the reference books and the clinicians'writing of the procedure is not detailed.It is suggested that coders carefully look for codes in the index and clinicians clearly write the purpose of surgery,so as to jointly promote the accuracy of ophthalmic coding.

关 键 词：编码 住院病案首页 手术名称 同名 眼科 

分 类 号：R197.323[医药卫生—卫生事业管理]