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目的分析甲状腺微创操作编码存在的问题,以提高编码质量。方法检索某院2013年1月1日至2014年12月31日住院行甲状腺微创操作的病案99份,回顾性分析病案首页手术操作的编码情况。结果手术操作编码漏编错编的共30份,错误率达30.3%,其中编码错误的2份,占2.0%,遗漏手术操作编码的28份,占28.3%。结论医学领域的新技术不断涌现,要做到准确编码,编码员必须学习相关专科的新理论新技术;认真阅读病案内容,积极主动与临床医师沟通,规范病案首页的填写,加强病案首页质量监控。
Objective To analyze the existing problems of minimally invasive thyroidectomy in order to improve the coding quality. Methods A total of 99 hospitalized cases with thyroid minimally invasive operation from January 1, 2013 to December 31, 2014 in our hospital were retrieved. The coding of the first surgical operation was retrospectively analyzed. Results A total of 30 surgical coding errors were found, with an error rate of 30.3%. Among them, 2 were incorrectly coded, accounting for 2.0%, while 28 were missing operative codes, accounting for 28.3%. Conclusions New technologies in the medical field are emerging constantly. To achieve accurate coding, the coder must learn the new theory and new technology of related specialties; carefully read the content of the medical records, actively communicate with the clinician, standardize the first page of the medical record, and strengthen the quality control of the first page of the medical record .