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目的探讨手术级别填写存在的问题,针对各问题提出改进措施,为精确手术级别信息提供合理建议。方法分析2015年1月1日-2015年12月31日期间手术级别构成情况,采取单纯随机方法抽取某院610例样本进行分析,找出手术级别填写存在的问题。结果一级二级手术比例分别是9.9%和41.1%,三级四级手术比例分别是44.5%和4.5%。手术级别填写完全正确仅占25%,手术级别信息未提取和医师填写手术级别低于实际级别所占的比例较大,分别是39%和21%。手术操作名称无对应编码和医师填写手术级别高于实际级别分别占6%和5%。结论手术级别信息未提取和医师填写手术级别低于实际级别是影响手术级别不正确的重要原因,针对原因需加强管理,完善医院软件系统,修订《手术分级目录》并增进编码员与临床医师的交流。
Objective To explore the existing problems in the filling of operative levels, propose improvement measures for each problem, and provide reasonable suggestions for accurate surgical level information. Methods The composition of the operative grade from January 1, 2015 to December 31, 2015 was analyzed. A simple random method was used to analyze 610 cases in a hospital to find out the existing problems in the filling of operative grade. Results The first-level two-stage surgery was 9.9% and 41.1% respectively, and the third and fourth-stage operations were 44.5% and 4.5% respectively. Completely correct surgical level fill only 25%, surgical level information is not extracted and the doctor filled in the surgery level lower than the actual level accounted for a larger proportion, respectively, 39% and 21%. Surgery name without corresponding coding and physician fill level higher than the actual level of surgery accounted for 6% and 5%. Conclusions The information of operation level is not extracted and the physician fill in the operation level is lower than the actual level is the important reason that affects the operation level is not correct. According to the reason, we should strengthen the management, improve the hospital software system, revising the “surgical classification catalog” and enhance the coder and clinician communicate with.