手术名称字典与手术分级管理

手术分级信息质量对手术分级管理至关重要。但是临床提供的手术名称和ICD-9-CM-3名称存在一定的差异,为获取高质量的手术分级信息,病案管理工作者应注重加强手术名称字典的维护工作和手术名称编目质量,同时加强与临床科室沟通和联系,提高手术名称书写的准确性,完善手术信息录入的审核,保障手术分级统计信息的准确性和各项评价指标的真实性。

Surgery Name Dictionary and Surgery Classification Management

Surgery classification information quality is very important to surgery classification management.But there are some differences between clinical surgery name and ICD-9-CM-3 surgery name.The medical records management workers should pay attention to and strengthen maintenance of operation name dictionary,make efforts to improve surgery coding quality,strengthen communication with clinical departments,improve the accuracy of surgery name,improve the quality of operation information input and review to obtain high quality surgery classification information,make sure the accuracy of surgery classification statistics information and the authenticity of evaluation indicators,ensure the implementation of surgery classification management.