某院甲状腺手术编码错误案例分析  

A Case Study of Coding Errors in Thyroid Surgery in a Hospital

作　　者：贺梦宇 吕方[1] 张丽[1] 谭笑梅 杜晓曦[1] He Mengyu;Lv Fang;Zhang Li;Tan Xiaomei;Du Xiaoxi(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》2023年第10期44-46,共3页Chinese Medical Record

摘　　要：甲状腺切除术作为外科常见手术,根据甲状腺手术操作分类原则,以手术切除范围和手术入路为分类轴心,将甲状腺切除术分为四个亚目:单侧甲状腺腺叶切除术06.2、其他部分甲状腺切除术06.3、甲状腺全部切除术06.4、胸骨下甲状腺切除术06.5。为重新梳理甲状腺手术编码的难点,减少甲状腺手术的错误编码数量,检索某院2020年5月1日至2021年5月31日的甲状腺手术病案533例,在编码质控员的指导下重新审核甲状腺手术的编码结果,其中正确编码504例,错误编码29例。对错误编码案例进行分析,归纳出手术切除范围错误和手术入路错误两种错误类型,总结出编码错误的原因是临床医师书写手术名称不规范及编码员错误理解编码规则,提出改进措施,要求编码员应加强和临床医师的沟通,提高责任意识并巩固专业知识。Thyroidectomy is a common surgical operation.According to the principle of thyroid operation classification,thyroidectomy can be divided into four subcategories based on the scope and approach of thyroidectomy.Unilateral thyroidectomy 06.2,other partial thyroidectomy 06.3,total thyroidectomy 06.4,substernal thyroidectomy 06.5.In order to re-clarify the difficulties of thyroid surgery coding and reduce the number of wrong coding of thyroid surgery,533 cases of thyroid surgery medical records from May 1st,2020 to May 31st,2021 were retrieved from a certain hospital,and the coding results of thyroid surgery were re-reviewed under the guidance of the coding quality control officer,among which 504 cases were correctly coded and 29 cases were incorrectly coded.By analyzing the cases of incorrect coding,two types of errors were summarized,namely,the error of surgical resection scope and the error of surgical approach.It was concluded that the reason for the error coding was that the clinician did not write the surgical name in a standard way and the coder misunderstood the coding rules.The improvement measures were put forward,and coders were required to strengthen the communication with clinicians,improve their sense of responsibility and consolidate their professional knowledge.

关 键 词：甲状腺 手术编码 手术切除范围 手术入路 

分 类 号：R653[医药卫生—外科学]