Analysis on Coding Quality of Intracranial Hemorrhage and Craniotomy Hematoma Evacuation
Objectives This study aims to analyze the causes of coding errors in intracranial hemorrhage and craniotomy hematoma removal and discuss the diagnostic coding and surgical coding of different bleeding sites,so as to improve coding accuracy.Methods Inpatient medical records with front pages of where the name of the physician's main operation included craniotomy hematoma evacuation or intracranial hematoma evacuation in a tertiary hospital from January 1,2021 to December 31,2022 were searched.A total of 227 medical records met the criteria.The accuracy of coding of major diagnoses and major surgeries was checked,and the causes of coding errors were analyzed.Results Among 227 medical records,12 cases were mainly diagnosed with error codes,with an error rate of 5.29％.Among them,the error rate of cerebral hemorrhage was the highest,accounting for 2.20％.The number of major surgical coding errors was 39 cases,with an error rate of 17.18％,among which intracerebral hematoma removal had the highest error rate of 18.88％.Analysis result showed that the reasons for errors were related to coders'failure to read medical records carefully,lack of relevant anatomical knowledge,lack of knowledge of such diseases and surgical coding,and non-standard writing of medical records.Conclusions The coding error rate of intracranial hemorrhage and intracranial hematoma removal is relatively high.Therefore,it is necessary to continuously strengthen the writing quality of doctors'medical records and improve the quality level of coders.Besides,it is also necessary to establish a long-term quality control mechanism to control and gradually improve the quality of the front page and coding.
NETL
NSTL
万方数据
维普
