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随着血管外科检查及手术技术的不断发展,相关诊断及手术操作也进一步细化。其具有诊断的疾病编码分类也更加细化、合并编码较多、手术操作复杂且易混淆等特点。疾病的分级、是否有合并症、病因的不同都会影响疾病的编码。通过对血管外科常见疾病和手术操作编码错误案例进行分析,可加深编码员对疾病和编码的理解,提高疾病和手术操作编码的准确性。通读病案,把握整体概况,避免断章取义,抓住重点,这是阅读病案的关键,同时要增强编码人员的医学知识和本专业知识,在实践中不断积累工作经验;加强对临床医师疾病分类知识的培训做到完整严谨的书写病案;编码员与临床医师保持良好的沟通,从而达到对血管外科疾病及手术的正确编码。
With the continuous development of vascular surgery and surgical techniques, relevant diagnoses and surgical procedures are further refined. Its diagnosis of disease coding classification is also more detailed, more combined coding, surgical operation is complex and easy to be confused and so on. Classification of diseases, whether there is a complication, the cause of the disease will affect the different coding. By analyzing common cases of vascular surgery and surgical coding errors, the coder’s understanding of the disease and coding can be deepened, and the accuracy of disease and surgical coding can be improved. Throughout the medical record, grasp the overall profile, to avoid out of context, to seize the key, which is the key to reading medical records, and to enhance the code of medical knowledge and expertise, in practice continue to accumulate work experience; to enhance knowledge of clinicians disease classification Training to complete a rigorous writing medical record; Coder and clinicians to maintain good communication, so as to achieve the correct coding of vascular surgery diseases and surgery.