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目的为了避免手术操作编码错误给将来医疗保险、商业保险准确付费造成较大误差,病案资料更能体现其学术价值和利用价值。方法2005年我们从病案中常见的清创缝合术这一不规范的手术术语编码入手,严格按ICD-9-CM-3操作步骤和编码原则确切编码并将这单一手术名称病案号逐一登记,每季在登记病案号中随机抽样30%病案进行手术编码核查、统计、比较,同时对错误编码病案在科内反馈分析,最后在外科手术病人2004年840份和2005年927份病案中以相同方法、随机抽样比例作手术编码核查、统计并作X2检验。结果2005年这单一不规范的手术术语编码准确率由第一季75%上升到第4季98%。2005年手术病人手术编码准确率比2004年提高6个百分点X2=9.46,X2>X20.005(1),P<0.005。2005年和2004年编码准确率是有差异的。结论2005年手术编码的操作方法和定期检查获得的正确编码效果优于2004年。
Objective In order to avoid coding errors in surgical operations, it will cause greater errors in the future payment of medical insurance and commercial insurance. The medical record data can better reflect its academic value and use value. Methods In 2005, we proceeded from the deregulation and surgical suturing technique commonly used in medical records to code the surgical terminology code strictly according to the ICD-9-CM-3 operation procedure and coding principle, and registered the single surgical name case number one by one. Each quarter, a random sample of 30% of medical records was registered in the Registered Case Number for surgical code verification, statistics, and comparisons. The erroneously coded medical records were also analyzed and analyzed in the department. Finally, 840 surgical patients and 927 medical records in 2005 were the same. Methods, random sampling ratios for surgical code verification, statistics and X2 test. Results In 2005, the accuracy rate of this single non-standardized surgical term code rose from 75% in the first quarter to 98% in the fourth quarter. In 2005, the surgical coding accuracy of surgical patients increased by 6 percentage points compared with that of 2004. X2 = 9.46, X2> X20.005 (1), P < 0.005. There was a difference in coding accuracy between 2005 and 2004. Conclusion The correct coding effect obtained by the operation method of the surgical coding in 2005 and regular inspections was better than in 2004.