CAJ | 학술논문

目的：检查本院眼科疾病诊断及手术操作编码情况，找出编码错误的根源。方法：随机抽查本院2011年1月-2012年12月本院眼科收治的出院病案238份，回顾性分析病案首页疾病诊断及手术操作的编码情况。结果：疾病诊断方面：主要诊断选择错误6例，错误率2.5%；疾病诊断填写不全18例，错误率7.6%；编码错误7例，错误率2.9%。手术操作方面：手术操作编码错误5例，错误率2.1%；手术及操作漏报造成编码遗漏10例，错误率4.2%。结论：做到正确编码，临床医生应加强编码知识的培训，准确、规范填写疾病诊断和手术操作名称；编码员要加强学习，养成阅读病案，多与临床医生沟通，按照编码原则编码的好习惯。
목적：검사본원안과질병진단급수술조작편마정황，조출편마착오적근원。방법：수궤추사본원2011년1월-2012년12월본원안과수치적출원병안238빈，회고성분석병안수혈질병진단급수술조작적편마정황。결과：질병진단방면：주요진단선택착오6례，착오솔2.5%；질병진단전사불전18례，착오솔7.6%；편마착오7례，착오솔2.9%。수술조작방면：수술조작편마착오5례，착오솔2.1%；수술급조작루보조성편마유루10례，착오솔4.2%。결론：주도정학편마，림상의생응가강편마지식적배훈，준학、규범전사질병진단화수술조작명칭；편마원요가강학습，양성열독병안，다여림상의생구통，안조편마원칙편마적호습관。
Objective:To check the code of the ophthalmology disease diagnosis and surgical operation in our hospital and to find the root cause of coding errors. Method:238 copies of medical records admitted to the Department of Ophthalmology in our hospital from January 2011 to December 2012 were checked in random sampling method,review of the diagnosis and surgical operation coding was analysis in medical record.Result:In main diagnosis coding:6 cases of disease diagnosis choice were wrong,error rate 2.5%;18 cases disease diagnosis were uncompleted,the error rate 7.6%;7 cases of coding were error,error rate 2.9%.In operation coding:5 cases of surgical operation code were error,error rate 2.1%;10 cases of coding were omission duo to the operating omissions,error rate 4.2%.Conclusion:To achieve the correct code,clinicians should enhance training in coding knowledge,fill in the disease diagnosis and operation names accurately and standard;coders should strengthen learning and should have the good habit of reading medical records, communicating with clinicians usually,coding medical records in accordance with the principles of coding.