急性心肌梗死常见编码问题分析  

Analysis of Common Coding Problems in Acute Myocardial Infarction

作　　者：付闪闪 Fu Shanshan(Liaocheng People’s Hospital,Liaocheng 252000,Shandong Province,China)

机构地区：[1]聊城市人民医院,山东省聊城市252000

出　　处：《中国病案》2024年第1期29-31,共3页Chinese Medical Record

摘　　要：目的分析急性心肌梗死的主要诊断及其手术操作常见的编码问题,并制定解决对策。方法利用医院信息检索系统检索2021年4月1日-2021年11月30日主要诊断编码为I21.-且包含主要手术编码为36.06或36.07的病案473份,逐份核查主要诊断和主要手术的选择及编码情况,并通过病历缺陷分析系统对其缺陷率进行统计分析。结果473份病案中,涉及主要诊断的缺陷病案36份,其中医师主要诊断选择错误病案8份,医师主要诊断填写笼统病案27份,编码员错编病案5份。涉及手术操作的缺陷病案14份,其中医师主要手术操作选择错误病案3份,编码员错编、漏编病案11份。结论住院病案首页急性心肌梗死主要诊断及主要手术的选择及编码仍存在质量问题,编码质量仍需进一步提高。Objectives This study aims to analyze the common coding problems of the main diagnoses of acute myocardial infarction and its surgical procedures and formulate solutions.Methods The hospital information retrieval system was used to retrieve 473 medical records from April 1,2021 to November 30,2021,with the main diagnosis code being I21.-and the main surgery code being 36.06 or 36.07.The selection and coding of major diagnoses and major surgeries were checked one by one and statistical analysis was performed on their defect rates through the medical record defect analysis system.Results Among the 473 medical records,there were 36 defective medical records involving the main diagnosis,including 8 cases where the physician chose the wrong main diagnosis,27 cases where the physician filled in the general diagnosis as the main diagnosis,and 5 cases where the coder made the wrong mistake.There were 14defective medical records involving surgical operations,including 3 medical records in which doctors selected the wrong main surgical operations,and 11 medical records were wrongly coded or omitted by coders.Conclusions There are still quality problems in the selection and coding of the main diagnosis of acute myocardial infarction and main operations on the front page of the medical records,and the coding quality still needs to be further improved.

关 键 词：冠状动脉支架植入术 ICD-9-CM-3 急性心肌梗死 主要诊断选择 主要手术操作选择 

分 类 号：R197.323[医药卫生—卫生事业管理]