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临床医师正确填写手术操作名称,是做好手术操作分类编码的关键,而手术编码索引的正确、完整与否,直接关系到今后手术操作资料的分析研究和合理使用。 病案是医疗、教学、科研工作的重要资料,是医院疾病分类和手术操作分类的基础。但目前在病案首页中手术操作名称的填写存在一些问题,影响编码的准确性,特提出讨论如下: 一、病案首页中手术操作名称正确的填写方法构成手术名称的成份包括:部位+术式+目的+器械(手法)+人路 例:阑尾切除术[部位(阑尾+术式(切除术)。
The clinician correctly fills in the surgical operation name, which is the key to the classification coding of the surgical operation. The correctness and completeness of the surgical coding index is directly related to the analysis and rational use of the surgical operation data in the future. Medical records are important data for medical treatment, teaching, and scientific research. They are the basis for classification of hospital diseases and classification of surgical operations. However, there are some problems in the name of surgery operation in the first page of the medical record, which affects the accuracy of the coding. The following are the discussions: 1. The correct name of the operation name in the first page of the medical record. The components that constitute the operation name include: Part + Surgical + Purpose + device (manipulation) + person example: appendectomy [site (appendix + surgery (excision).