手外科常见疾病诊断和手术操作编码思路分析  

Common diseases diagnosis and surgical procedure coding in hand surgery

作　　者：余艳 蔡庆婷 刘体娟 黄云 李松[1] 宋雯 Yu Yan;Cai Qingting;Liu Tijuan;Huang Yun;Li Song;Song Wen(Department of Medical Record,Anshun People's Hospital,Anshun,Guizhou 561000,China)

机构地区：[1]贵州省安顺市人民医院病案科,贵州安顺561000

出　　处：《实用医技杂志》2023年第10期726-730,共5页Journal of Practical Medical Techniques

摘　　要：目的对手外科常见疾病的诊断编码与手术操作编码进行分析,明确相关编码的具体要求。方法选择2018年1月至2023年6月在贵州省安顺市人民医院进行手外科诊断与手术治疗的患者共5000份病历,其中有1609份编码在S60-S69的病历开展深入分析。在实际研究中,调取1400例患者的住院信息以及疾病情况进行深入分析,并完成手术操作编码分析与总结工作。结果对调取的1400例病例进行总结性分析,确定其中2个部位及2个以上部位外伤类疾病1250例,占89.29%;单个部位损伤150例,占10.71%。进行手术治疗完成2种及2种以上手术治疗的患者共1168例,占83.43%,仅仅接受1种手术治疗的患者为54例,占比约为3.86%,并未开展手术治疗的有178例,占12.71%。结论手外科患者在诊断治疗过程中手部外伤所占比例大,而腕部与手部的损伤是其中的主要损伤部位。在编码操作过程中必须对手部解剖结构进行全面掌握,并且要根据详细完善的手术记录,提高编码的准确率。Objective To analyze the diagnosis codes and operation codes of common diseases in hand surgery,and make clear the specific requirements of related codes.Methods A total of 5000 medical records were selected from patients who underwent hand surgery diagnosis and surgical treatment in Anshun People's Hospital of Guizhou Province from January 2018 to June 2023.Among them,1609 medical records within the S60-S69 were analyzed in depth.In the actual research,the hospitalization information and disease situation of 1400 cases were collected for in-depth analysis,and the operation code analysis and summary were completed.Results A summative analysis was made on 1400 cases.A total of 1250 cases of traumatic diseases in two or more parts were identified,accounting for 89.29%.There were 150 cases of single site injury,accounting for 10.71%.A total of 1168 patients underwent two or more kinds of surgical treatment,accounting for 83.43%;54 patients received only one kind of surgical treatment,accounting for about 3.86%;178 patients did not receive surgical treatment,accounting for 12.71%.Conclusion Hand injuries account for a large proportion in the diagnosis and treatment of hand surgery patients,and wrist and hand injuries are the main injury sites.In the process of coding,the anatomical structure of the hand must be fully mastered,and improve the accuracy of coding according to the detailed and perfect surgical records.

关 键 词：手损伤 诊断 临床编码 

分 类 号：R658.2[医药卫生—外科学] R197.323[医药卫生—临床医学]