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目的分析疾病分类和手术操作分类的常见错误,以提高疾病分类和手术分类质量。方法采用某三甲医院2013年5月-2014年4月每月抽查病案80份,进行疾病和手术分类编码检查,分析错误原因。结果共抽取病案960份,发现问题病案92份。其中涉及疾病分类编码错误的58份,错误率为6.0%。涉及手术操作分类错误的34份,错误率为3.5%。结论编码错误原因与编码员责任心不足,阅读病案不细致,以及对疾病认识不足、对疾病分类的原则掌握不够有关。科室质量小组的常态检查是提高编码质量的有效措施。
Objective To analyze the common mistakes in the classification of diseases and the classification of surgical operations so as to improve the classification of diseases and the quality of surgical classification. Methods A total of 80 cases were randomly selected from a top-rank hospital from May 2013 to April 2014 for disease screening and surgical classification, and the causes of errors were analyzed. Results A total of 960 medical records were taken and 92 medical records were found. Of these, 58 were classified as wrongly coded in the disease classification and the error rate was 6.0%. There were 34 mistakes involved in the classification of surgical procedures, with an error rate of 3.5%. Conclusion The reason of coding error and coder ’s sense of responsibility, read the case is not meticulous, and lack of understanding of the disease, the classification of the disease is not enough grasp of the principle. The normal inspection of the department quality team is an effective measure to improve the coding quality.