某医院皮肤移植术错误手术编码情况分析  

Analysis of Wrong Operation Code of Skin Grafting in a Hospital

作　　者：房丽军 Fang Lijun(Department of Medical Record Management,Zibo Municipal Hospital,Zibo 255400,Shandong Province,China)

机构地区：[1]山东省淄博市市立医院病案管理科,山东淄博255400

出　　处：《中国社区医师》2023年第27期161-163,共3页Chinese Community Doctors

摘　　要：目的:分析某医院皮肤移植术错误手术编码情况。方法:选取2021年1月—2022年6月山东省淄博市市立医院手术编码中存在86.6游离皮肤移植或(和)86.7带蒂皮瓣或皮瓣移植的病案109份作为研究对象。依据国际疾病分类第9版临床修订本第3卷(ICD-9-CM-3)原则审核皮肤移植术的手术编码。统计手术编码错误病案数和错误问题数,分析错误类型及错误率,并讨论经典案例。结果:病案手术编码错误率为46.79%(51/109),错误87处,错误最多为漏编皮瓣制备,占比26.44%,其余错误从多到少依次为漏编皮片移植物类型、漏编皮瓣附着、多编皮肤切除用作移植物、皮瓣附着、错编为皮瓣修复。结论:皮肤移植术手术编码错误较多,编码员需加强编码规则及临床知识的学习,按编码操作程序正确编码,提高编码正确率。Objective:To analyze the wrong operation code of skin grafting in a hospital.Methods:A total of 109 medical records with 86.6 free skin grafts or(and)86.7 pedicle skin flap or skin flap grafts in the operation code of Shandong Province Zibo Municipal Hospital from January 2021 to June 2022 were selected.According to the principle of International Classification of Diseases,Ninth Revision,Clinical Modification,Volume 3(ICD-9-CM-3),the operation code of skin grafting was reviewed,the number of wrong medical records and wrong problems in operation code was counted,the error type and error rate were analyzed,and the typical case was discussed.Results:The error rate of operation code in medical records was 46.79%(51/109),87 errors in total.The most error was missing coding for preparation of skin flap,accounting for 26.44%,and the remaining errors were ranked as follows:missing coding for type of skin graft,missing coding for attachment of skin flap,redundant coding for graft of skin excision,flap attachment,miscoding for skin flap repair.Conclusion:There are many wrong operation codes in skin grafting,coders should strengthen the learning of coding rules and clinical knowledge,perform correct coding according to coding operation procedures to increase coding accuracy.

关 键 词：皮肤移植术 ICD-9-CM-3 手术分类 

分 类 号：R197.323[医药卫生—卫生事业管理]