蝶鞍区占位疾病与手术编码质量分析  

Analysis of Diseases and Surgical Coding Quality of Occupied Lesions in Sella Region

作　　者：张欣欣[1] 张文[1] 苟瑜坤 孔德莹 Zhang Xinxin;Zhang Wen;Gou Yukun;Kong Deying(The First Affiliated Hospital of Xi'an Jiaotong University,Xi'an 710061,Shaanxi Province,China;不详)

机构地区：[1]西安交通大学第一附属医院,陕西省西安市710061

出　　处：《中国病案》2024年第11期22-24,共3页Chinese Medical Record

基　　金：国家卫健委卫生健康统计工作高质量发展揭榜攻关项目;陕西省自然科学基础研究计划青年项目(2022JQ-750);西安市创新能力强基计划-医学研究项目(21YXYJ0112)。

摘　　要：目的通过分析蝶鞍区占位的疾病及手术编码错误原因,探讨该类疾病及手术的正确编码,提高编码的准确率。方法检索某三甲医院2020年1月1日-2023年8月31日出院病案首页中门诊诊断为鞍区占位性病变且住院期间进行了相应手术的病案共285份。对这部分病案进行编码质控及问题分析。结果250例为肿瘤性疾病,35例为非肿瘤性疾病。总体疾病诊断编码正确率为91.22%,手术编码准确率为81.75%。非肿瘤性疾病手术编码错误率最高,为42.86%。错误原因与编码员缺乏相关解剖学知识,混淆手术切除部位、未仔细阅读手术记录等原因有关。结论蝶鞍区占位疾病的手术编码错误率较高,编码员需加强相关临床知识的学习,仔细阅读病案资料,不断提高编码质量。Objectives This study aims to analyze the causes of coding errors in diseases and surgeries involving space-occupying masses in the sella turcica area,explores the correct coding for such diseases and surgeries,and improves the accuracy of coding.Methods A total of 285 medical records were retrieved from the front page of discharge medical records of a tertiary hospital from January 1,2020 to August 31,2023,which showed an outpatient diagnosis of sellar space-occupying lesions and corresponding surgery during hospitalization.Coding quality control and problem analysis were conducted on these medical records.Results 250 cases were neoplastic diseases,and 35 cases were non-neoplastic diseases.The overall disease diagnosis coding accuracy rate was 91.22%,and the surgery coding accuracy rate was 81.75%.The coding error rate for surgeries for non-neoplastic diseases was the highest,at 42.86%.The causes of the errors were related to the coders'lack of relevant anatomical knowledge,confusion about the surgical resection site,and failure to read the surgical records carefully.Conclusions The surgical coding error rate of occupied lesions in the sella region is high.Coders need to strengthen the learning of relevant clinical knowledge,read medical records carefully,and continuously improve the quality of coding.

关 键 词：蝶鞍区占位疾病 疾病编码 手术编码 编码质量 

分 类 号：R197.323[医药卫生—卫生事业管理] R651[医药卫生—公共卫生与预防医学]