Analysis of Common Coding Problems in Acute Myocardial Infarction
Objectives This study aims to analyze the common coding problems of the main diagnoses of acute myocardial infarction and its surgical procedures and formulate solutions.Methods The hospital information retrieval system was used to retrieve 473 medical records from April 1,2021 to November 30,2021,with the main diagnosis code being I21.-and the main surgery code being 36.06 or 36.07.The selection and coding of major diagnoses and major surgeries were checked one by one and statistical analysis was performed on their defect rates through the medical record defect analysis system.Results Among the 473 medical records,there were 36 defective medical records involving the main diagnosis,including 8 cases where the physician chose the wrong main diagnosis,27 cases where the physician filled in the general diagnosis as the main diagnosis,and 5 cases where the coder made the wrong mistake.There were 14 defective medical records involving surgical operations,including 3 medical records in which doctors selected the wrong main surgical operations,and 11 medical records were wrongly coded or omitted by coders.Conclusions There are still quality problems in the selection and coding of the main diagnosis of acute myocardial infarction and main operations on the front page of the medical records,and the coding quality still needs to be further improved.
NETL
NSTL
万方数据
维普
