乳腺肿瘤术后乳房再造手术ICD-9-CM-3编码剖析  

Analysis of ICD-9-CM-3 coding in postoperative breast reconstruction surgery for breast tumors

作　　者：李媛 王洪涛 高丽娜 车凡 王春梅 LI Yuan;WANG Hongtao;GAO Lina;CHE Fan;WANG Chunmei(Tianjin Medical University Cancer Institute&Hospital,National Clinical Research Center for Cancer,Tianjin Clinical Research Center for Cancer,Key Laboratory of Cancer Prevention and Treatment,Tianjin 300060,China)

机构地区：[1]天津市肿瘤医院天津医科大学肿瘤医院//国家恶性肿瘤临床医学研究中心//天津市恶性肿瘤临床医学研究中心//天津市肿瘤防治重点实验室,天津300060

出　　处：《现代医院》2023年第10期1526-1530,共5页Modern Hospitals

基　　金：天津市医学重点学科(专科)建设项目(TJYXZDXK-012A)。

摘　　要：目的 分析某三甲肿瘤专科医院乳腺肿瘤术后乳房再造手术ICD-9-CM-3编码错误的案例,规范临床医师首页填写的正确性,弥补病案首页编码员编码知识存在的缺陷,提高乳房再造手术ICD-9-CM-3编码的准确性。方法 调取某三甲肿瘤专科医院2023年1月—6月出院病案,按照ICD-9-CM-3手术编码相关原则进行检索,并对其病历首页手术及操作中主要操作与其他操作进行质控和分析。用Excel表格进行错误类型的统计工作。结果 质控乳房再造手术病案首页365份,存在缺陷份数34份,占9.32%,错误类型包括主手术编码错误8份,占23.53%,其他手术操作编码错误11份,占32.35%,漏填手术操作15份,占44.12%。结论 病案首页手术操作编码准确性与准确性的提高,需要医院医疗管理部门、临床诊疗医师、病案管理部门及信息网络部门的加强管理、深化沟通和共同学习,进而促进全院病案首页编码水平逐步提高。Objective This paper analyzed the case of ICD-9-CM-3 coding error in breast reconstruction surgery after breast tumor surgery in a tertiary cancer hospital,standardized the correctness of clinicians' homepage filling,made up for the shortcomings of the coding knowledge of the coder on the first page of the medical record,and improved the accuracy of ICD-9-CM-3 coding for breast reconstruction surgery.Methods The discharge cases of a tertiary cancer hospital from January to June 2023 were retrieved in line with the relevant principles of ICD-9-CM-3 surgical coding,and the quality control and analysis of the main operations and other operations during the operation on the home page of its medical records were carried out.Excel spreadsheets were employed sort out error types.Results Of the 365 cases of quality control breast reconstruction surgery,34 were defective cases,accounting for 9.32%;8 errors in the coding of the main operation,accounting for 23.53%,11 coding errors in other surgical operations,accounting for 32.35%,and 15 missing surgical operations,accounting for 44.12%.Conclusion The improvement of the accuracy and accuracy of surgical operation coding on the home page of medical records requires the strengthening of management,deepening communication and joint learning of hospital medical management departments,clinical diagnosis and treatment physicians,case management departments and information network departments,so as to promote the gradual improvement of the coding level of the home page of hospital records.

关 键 词：乳腺肿瘤术后 乳房再造手术 ICD-9-CM-3编码 

分 类 号：R197.323.1[医药卫生—卫生事业管理]