Analysis on Surgical Operation Code Coverage in a Three A and Tertiary General Hospital
Objectives To analyze the coverage rate of surgical operation code in a Three A and Tertiary General Hospital in the past 5 years,and provide data support and reference for the improvement of coding quality and hospital management.Methods A 855654 cases containing surgical operation codes from January 1st,2018 to December 31st,2022 of a Three A and Tertiary General Hospital were collected,and all surgical operation codes on the front pages of their inpatient cases(2452454)were compared with the national clinical version 3.0,and the coverage was counted and the reasons for not covered were analyzed.Results The coverage rate of surgical operation codes increased year by year,from 25.69%to 39.19%.A total of 6152 surgical operation codes were not covered,of which 3698 were not carried out(2459 were capable but not carried out,1239 were unable to carry out),and 2454 were carried out but not covered(of which 6.48%were due to omissions).Conclusions In the code of operation not covered,the code of the hospital did not carry out surgery accounted for the highest proportion.The hospital should actively develop new technology,advanced technology and difficult technology to improve the level of medical service.At the same time,the coding quality and the data quality of the front page of the inpatient medical records were improved by establishing the mechanism of communication and cooperation between the medical records and the clinical records,the whole process management of the information-based medical records and the construction of the medical records professionals.
Coding of surgical operationsCoverageNew technology developmentCoding quality
NETL
NSTL
万方数据
