目的 分析核查某院骨科手术编码情况,提高骨科手术编码的准确性.方法 随机抽取某院2015年1月至2016年12月268份进行手术治疗的骨科住院病案,回顾性分析手术操作的编码情况.结果 268份骨科手术病例病案首页手术编码错误6例,错误率2.2 %;手术编码遗漏19例,错误率7%;手术名称与手术内容不一致10例,错误率3.7%;手术记录遗漏内容7例,错误率2.6%.结论 编码员对疾病分类编码原则掌握不熟练,对临床手术过程不了解,未详细阅读手术记录是造成编码错误的主要原因;临床医师规范手术操作名称书写,提高病历书写质量,加强编码员与临床医师的沟通也是提高编码质量的重要措施.%Objective To analyze and inspect the situation of operation coding of orthopaedic in our hospital. To improve the accuracy of orthopaedic operation coding. Methods Randomly selected orthopaedics medical record of our hospital beteen January 2015 to December 2016. The operation coding were analyzed. Results Six cases of coding error, accounted for 2.2%; 19 cases of coding omission, accounted for 7%; 10 cases of the operation name is inconsistent with the operation content, accounted for 3.7%; 7 cases of the operation contents were omitted, accounted for 2.6 %. Conclusion To improve the operation quality of hand coding, coding staff to enhance professional knowledge and clinical knowledge, develop the habit of reading medical records, and actively communicate with clinicians, seriously implement the ICD encoding principle; on the other hand strengthen the clinician ICD encoding knowledge training, standardize the operation name writing, improve the quality of medical records.
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