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目的探讨心血管外科疾病诊断及手术操作编码情况。方法收集2013年1月至2015年1月本溪市金山医院心血管外科收治的64例患者资料,对64份病案的诊断情况及手术操作编码情况进行回顾性分析。结果 64例病案中出现疾病诊断方面编码缺陷14例,占21.9%;出现手术操作方面编码缺陷10例,占15.6%。结论心血管外科疾病诊断及手术操作编码操作较常见,应加强对临床医师及编码员的培训,严格遵循国际疾病分类编码原则对确保编码变化准确具有重要价值。
Objective To investigate the diagnosis and surgical operation of cardiovascular diseases. Methods The data of 64 patients admitted from January 2013 to January 2015 in Jinshan Hospital of Benxi City were collected and analyzed retrospectively on the diagnosis of 64 cases and the surgical operation codes. Results There were 14 coding defects in disease diagnosis in 21 of 64 cases, accounting for 21.9%. There were 10 coding defects in surgical operation, accounting for 15.6%. Conclusions The diagnosis and operation of cardiovascular surgery are more common. The training of clinicians and coders should be strengthened. To strictly follow the principle of international classification of diseases should be of great value to ensure the accuracy of coding changes.