摘要：
目的 分析1CD-9-CM-3编码名称和临床手术同名,易错用的编码.方法 回顾2015年-2016年某院手术操作包含肺癌、直肠癌、膀胱癌全切、输卵管异位妊娠、肝癌介入治疗5类手术患者的住院病案,统计与临床书写同名错用手术操作编码的类型以及错误编码率.结果 发生同名错用的手术操作包括肺叶切除术伴淋巴结清扫术,错编到32.6胸腔结构的根治性清扫,错误率12.17％、直肠根治术有明确的各种术式,错编到48.69其他直肠切除术,错误率15.36％、回肠膀胱术错编到57.87膀胱重建中的回肠代膀胱,错误率57.78％、输卵管异位妊娠行单侧输卵管切除术,错编到66.4单侧输卵管切除术,错误率16.13％,肝癌化疗栓塞,只编码39.79肝动脉栓塞术,错误率13.84％,共173例,总错误率16.17％.结论 ICD-9-CM-3编码名称和临床书写同名不一定就使用该编码,除要掌握分类知识,还要学习相关临床知识,仔细阅读病案,得到正确编码.%Objectives To analyze the clinical surgical operation coding of the same name and misuse with ICD-9-CM-3 encoding name.Methods To retrospectively analyze the hospitalized medical records of 5 kinds of operation patients included lung cancer,rectal cancer,bladder cancer total resection,tubal ectopic pregnancy,liver cancer interventional operation from 2015 to 2016.To conduct a statistical analysis on the coding types and error coding rate of the surgical operation coding of the same name and misuse with clinical writing.Results The occurrence of the same mistake in operation including lung resection with lymph node cleaning technique miscode until 32.6 chest structure of radical cleaning,error rate was 12.17％,rectum treated with clear all kinds of operation,wrong to 48.69 other rectum resection,error rate was 15.36％,ileal bladder reconstruction in the bladder reconstruction of 57.87 bladder,the error rate was 57.78％,the unilateral tubal resection of ectopic pregnancy was miscoded to 66.4 unilateral tubal resection,and the error rate was 16.13％,hepatocellular carcinoma chemoembolism,with only 39.79 hepatic arterial embolization,the error rate was 13.8d％.A total of 173 cases,the total error rate was 16.17％.Conclusions The same name of the ICD-9-CM-3 code and the name of the clinical writing were not necessarily use the coding.In addition to the classification of knowledge,we should learn relevant clinical knowledge,read the case carefully so as to get the correct coding.
