某三甲综合医院手术操作编码覆盖率分析  

Analysis on Surgical Operation Code Coverage in a Three A and Tertiary General Hospital

作　　者：李国静 周艾婧 全华艳 罗建[1] 莫春梅[1] Li Guojing;Zhou Aijing;Quan Huayan;Luo Jian;Mo Chunmei(Department of Medical Records,West China Hospital,Sichuan University,Chengdu 610041,Sichuan Province,China)

机构地区：[1]四川大学华西医院病案科,四川省成都市610041

出　　处：《中国病案》2024年第4期9-11,共3页Chinese Medical Record

摘　　要：目的分析某三甲综合医院近5年手术操作编码覆盖率,为编码质量的提高和医院管理提供数据支撑和参考。方法调取某三级甲等综合医院2018年1月1日-2022年12月31日含手术操作编码的病例855654份,将其住院病案首页所有手术操作编码(共2452454条)与国家临床版3.0进行比较,统计覆盖率并分析未覆盖的原因。结果手术操作编码覆盖率逐年升高,从25.69%提升至39.19%,2022年覆盖5382条。共6152条手术操作编码未覆盖,其中未开展未覆盖3698条(有能力开展但未开展2459条,无能力开展1239条),开展但未覆盖2454条(其中6.48%是因为漏编)。结论未覆盖手术操作编码中,该院未开展手术的编码占比最高,该院应积极开展新技术、先进技术和疑难技术,提高医疗服务水平。同时,通过建立病案-临床沟通协作机制、信息化的住院病案首页全流程治理和加强病案专业人才队伍建设来提高编码质量、提升住院病案首页数据质量。Objectives To analyze the coverage rate of surgical operation code in a Three A and Tertiary General Hospital in the past 5 years,and provide data support and reference for the improvement of coding quality and hospital management.Methods A 855654 cases containing surgical operation codes from January 1st,2018 to December 31st,2022 of a Three A and Tertiary General Hospital were collected,and all surgical operation codes on the front pages of their inpatient cases(2452454)were compared with the national clinical version 3.0,and the coverage was counted and the reasons for not covered were analyzed.Results The coverage rate of surgical operation codes increased year by year,from 25.69%to 39.19%.A total of 6152 surgical operation codes were not covered,of which 3698 were not carried out(2459 were capable but not carried out,1239 were unable to carry out),and 2454 were carried out but not covered(of which 6.48%were due to omissions).Conclusions In the code of operation not covered,the code of the hospital did not carry out surgery accounted for the highest proportion.The hospital should actively develop new technology,advanced technology and difficult technology to improve the level of medical service.At the same time,the coding quality and the data quality of the front page of the inpatient medical records were improved by establishing the mechanism of communication and cooperation between the medical records and the clinical records,the whole process management of the information-based medical records and the construction of the medical records professionals.

关 键 词：手术操作编码 覆盖率 新技术开展 编码质量 

分 类 号：R197.32[医药卫生—卫生事业管理]