Objectives To discuss the problems existing in the filling of operations level, put forward the relevant improvement measures, and provide reasonable suggestions for accurate the information of operations level. Methods To analyze the constitution situation of operations level from January 1st to December 31stin 2015, and then analyzed 610 samples which were selected with the application of simple random sampling method in a hospital, found out the problems existing in the filling of operations level. Results The percentage of primary surgery and secondary surgery were 9.9% and 41.1% respectively, and the percentage of triple surgery and four-stage surgery were 44.5% and 4.5%. The percentage of correctly surgery grading was 25%, surgery grading information was not extracted and surgery grading was written lower account for largest percentage, were 39% and 21% respectively.The percentage of operation name was not coding and surgery grading was written higher were 6% and 5%. Conclusions The important reasons effected the incorrect operations level included surgery grading information was not extracted and surgery grading was written lower than the real level. We should strengthen the management for these reasons, improve and perfect hospital management system, revise "Hierarchical directory operation" and improve the communication between coders and clinicians.%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.
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