简介:摘要目的探讨影响手术及操作名称单、双侧分类质量原因,提高手术操作分类质量。方法通过统计分析《手术与操作第九版临床修订本ICD-9-CM-32011版》书中各章节分类中需要单侧、双侧分类的手术操作部位容易出现错误的问题,提出解决的相应措施。结果影响手术操作分类质量的原因主要是手术名称书写不准确,编码员业务能力较低造成。结论加强业务培训提高临床医生书写手术名称水平及提高编码员对手术操作分类规则、医学基础知识的掌握是提高手术操作分类的有效措施。
简介:摘要探讨冠心病的相关手术编码的分类及查找方法。随着新技术、新理念的出现,冠心病的诊断及治疗的方法日趋多样化,本文主要针对介入心脏病学中的诊断及治疗方法、外科开胸手术编码给予探讨
简介:摘要 :为提高我院冠状动脉支架置入术的ICD-9-CM-3编码质量,归纳总结冠状动脉支架置入术的编码规则,为编码员在阅读此类病案时提供手术编码标准及附加编码方案,编码员需仔细阅读完整病案及手术记录,以求更加准确的编码此类手术。
简介:摘要ICD-9-CM-3是美国国际疾病分类临床修订本(第三卷)手术操作分类部分的编码规范指南,也是我国目前统一使用的标准编码方法,是医院病案质量管理的一部分。ICD-9-CM-3通过把临床各类手术性操作规范编码,为医院统计、科研、教学,医疗和医院管理提供了大量医疗信息检索,在国外这一编码还被广泛用于病种费用控制、医疗质量评估等工作。美国正在考虑建立全国性的电子病历系统,随着我国医疗保障体系的健全,第三方支付模式的需要,统一规范的疾病、手术操作名称、编码也是势在必行。但在临床工作中,医疗服务收费项目中手术名称与国际手术操作编码的冲突问题正在越来越影响正常工作的开展。实际工作中,由于分类标准编码的技术性较强,分类操作技能要求较高,而临床情况又复杂多样等因素,常常出现分类编码错误的情况。本文简要分析了ICD-9-CM-3在医院管理中存在的问题及作用。
简介:摘要 目的:通过对人工股骨头置换手术编码进行分析,提高编码员编码的准确性。方法:自某医院病案管理系统抽取2019年11月~2021年7月期间行人工股骨头置换术的病历,共计179份,按照《国际疾病分类第九版临床修订本手术与操作ICD-9-CM-3》第九版(2011修订版)编码原则进行对照分析,统计其中另编码轴面的病历数量。结果:179份病例中只有5份病历另编码轴面(00.74-00.78),仅占2.8%。结论:编码员对手术分类掌握不熟,主动与临床医师沟通意识不强;需加强与同行交流,以提高手术编码质量。
简介:临终患者停用ICD关掉,可以让患者免受疼痛和折磨。2011年3月《健康通讯》的头版文章介绍了植入型心律转复除颤器(简称ICD)。当心脏跳动太快或不规则时,这种装置可以除去心脏颤动,使其恢复正常心律。ICD约微型手机大小,经手术安置于锁骨下方的皮肤底下。
简介:AbstractPurpose:The reliability of trauma coding is essential in establishing the reliable trauma data and adopting efficient control and monitoring policies. The present study aimed to determine the reliability of trauma coding in educational hospitals affiliated to Shahid Beheshti University of Medical Sciences, Iran.Methods:In this descriptive cross-sectional study, 591 coded medical records with a trauma diagnosis in 2018 were selected and recoded by two coders. The reliability of trauma coding was calculated using Cohen's kappa. The data were recorded in a checklist, in which the validity of the content had been confirmed by experts.Results:The reliability of the coding related to the nature of trauma in research units was 0.75—0.77, indicating moderate reliability. Also, the reliability of the coding of external causes of trauma was 0.57—0.58, suggesting poor reliability.Conclusion:The reliability of trauma coding both in terms of the nature of trauma and the external causes of trauma does not have a good status in the research units. This can be due to the complex coding of trauma, poor documentation of the cases, and not studying the entire case. Therefore, holding training courses for coders, offering training on the accurate documentation to other service providers, and periodically auditing the medical coding are recommended.
简介:2011年11月10-14日,国际牙医师学院(InternationalCollegeofDentists,ICD)国际理事会(IntemationalCouncilMeeting)在印度新德里召开,会议由ICD2011年度主席Dr.CharlesLSiroky主持。ICD国际理事、中国区主席周学东教授委派胡涛教授及沈颉飞博士一行作为中国区代表出席了会议,并汇报了本区2011年度的工作,受到了ICD国际理事会的高度评价。同时,大会讨论通过了新1届的ICD主席及执行理事会人选,遴选了ICD新的标志,并决定在美国旧金山召开2012年ICD国际理事会。
简介:AbstractBackground:Models to predict mortality in trauma play an important role in outcome prediction and severity adjustment, which informs trauma quality assessment and research. Hospitals in China typically use the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) to describe injury. However, there is no suitable prediction model for China. This study attempts to develop a new mortality prediction model based on the ICD-10-CM lexicon and a Chinese database.Methods:This retrospective study extracted the data of all trauma patients admitted to the Beijing Red Cross Emergency Center, from January 2012 to July 2018 (n = 40,205). We used relevant predictive variables to establish a prediction model following logistic regression analysis. The performance of the model was assessed based on discrimination and calibration. The bootstrapping method was used for internal validation and adjustment of model performance.Results:Sex, age, new region-severity codes, comorbidities, traumatic shock, and coma were finally included in the new model as key predictors of mortality. Among them, coma and traumatic shock had the highest scores in the model. The discrimination and calibration of this model were significant, and the internal validation performance was good. The values of the area under the curve and Brier score for the new model were 0.9640 and 0.0177, respectively; after adjustment of the bootstrapping method, they were 0.9630 and 0.0178, respectively.Conclusions:The new model (China Mortality Prediction Model in Trauma based on the ICD-10-CM lexicon) showed great discrimination and calibration, and performed well in internal validation; it should be further verified externally.