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目的提高鼓室成形术手术编码的准确率。方法利用病案管理系统检索某院2013年8月1日-2017年5月8日期间病案首页中手术为鼓室手术的病例145例,以国际疾病分类第九版临床修订本ICD-9-CM-3手术及医疗操作分类为依据,根据手术记录中描述重新核对手术编码,对核对情况进行汇总分析。结果根据手术记录应编码为鼓室成形术的133例,编码员编码正确的为84例,占总数63.2%,其中Ⅰ型鼓室成形术为75例,占总数56.4%,Ⅱ型鼓室成形术为2例,占总数1.5%,Ⅲ型鼓室成形术为5例,占总数3.8%,Ⅳ型鼓室成形术为2例,占总数1.5%,Ⅴ型无;编码存在缺陷的49例,占总数36.8%,其中由于编码员未仔细阅读病案,以致错误编码成鼓室成形修正术为9例,占错误总数18.4%,分型错误的为38例,占错误总数77.6%。临床医师手术名称填写有误而编码员未详细阅读手术记录多编1例,占错误总数2.0%,漏编1例,占错误总数2.0%。临床医师手术记录未写明分型的89例,占66.9%,写明分型的为44例,占33.1%。结论临床医师应根据实际情况选择适宜的手术分型,规范书写手术记录和手术名称;编码员必须仔细阅读手术记录,遇到问题主动与手术医师沟通,提高责任心,临床医师与编码员共同努力,才能提高鼓室成形术编码的准确性。
Objective To improve the accuracy of tympanoplasty surgery coding. Methods A case record management system was used to search 145 cases of tympanic surgery in the first page of a hospital from August 1, 2013 to May 8, 2017. The revised version of ICD-9-CM- 3 surgical and medical operations as the basis for classification, according to surgical records described in the re-check the surgical coding, check the situation for a summary analysis. Results According to the surgical records should be encoded as tympanoplasty in 133 cases, the coder encodes correctly for 84 cases, accounting for 63.2% of the total, of which type Ⅰ tympanoplasty was 75 cases, accounting for 56.4% of the total, type Ⅱ tympanoplasty 2 Cases, accounting for 1.5% of the total, type III tympanoplasty in 5 cases, accounting for 3.8% of the total, type IV tympanoplasty in 2 cases, accounting for 1.5% of the total, Ⅴ type no; coding defects in 49 cases, accounting for 36.8% Among them, 9 cases were mistakenly coded as tympanum, accounting for 18.4% of total errors, 38 cases of wrong typing, accounting for 77.6% of the total errors, as the coder did not read the medical records carefully. Clinicians fill in the name of the operation was wrong and the coder did not read the surgical records in more than one editor, accounting for 2.0% of the total number of errors, 1 missing, accounting for 2.0% of the total number of errors. Clinicians did not record 89 cases of surgical records, accounting for 66.9%, indicating 44 cases of typing, accounting for 33.1%. Conclusion Clinicians should select the appropriate surgical classification according to the actual situation, standardize the written surgical records and surgical names; the coder must carefully read the surgical records, encounter problems and take the initiative to communicate with the surgeon to improve the sense of responsibility, clinicians and coders work together , In order to improve the tympanoplasty encoding accuracy.