사용자 수술명과 수술분류 code (ICD-9-CM) 일치율 향상에 관한 연구 (수술실 OCS program 사용 활성화를 통하여)

최향하; 김미영; 김도진; 유지원; 장정화; 박수정; 박재성

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자료유형: 학술저널

저자정보: 최향하 (순천향대학교 부천병원 의무기록팀) 김미영 (순천향대학교 부천병원 QI실) 김도진 (순천향대학교 부천병원 호흡기알레르기내과) 유지원 (순천향대학교 부천병원 의무기록팀) 장정화 (순천향대학교 부천병원 의무기록팀) 박수정 (순천향대학교 부천병원 수술실) 박재성 (순천향대학교 부천병원 QI실)

저널정보: 한국의료질향상학회 한국의료질향상학회지 한국의료질향상학회지 제12권 제1호

발행연도: 2006.1

수록면: 104 - 112 (9page)

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Background : The necessity of unify and standardize codes used at hospital has been emphasized since OCS (Order Communicating System) was adopted. Therefore, the purpose of this study were to standardize operation code by continuous training of the ICD-9-CM code that is used as standard code in OCS program at operating room. Method : In 400 operation data, operation code entered in OCS program at operating room was compared to operation name recorded in medical record. In addition, a matching rate between input data of operation code by medical record department and computing input data of operation code in 3,710 cases was compared for each department. User operation name and operation code were matched and major diagnosis by operation department and operation name were also matched. Results : User operation name was reflected in operation classification code in detail, and operation code entered on user was registered. Input rate and matching rate of operation code were gradually improved after improvement activity. In particular, a matching rate was high at ophthalmology where operation name is segmented. Plastic surgery and orthopedics with a lot of emergency operation and comprehensive operation name show low input rates. Conclusions : As the medical field makes progress in computerlization, awareness of information exchange and sharing becomes higher. Among codes to classified medical institution, codes related to surgical operation are all different by user of hospital and department. Computerlization and standardization is essential. And when efforts of standardization continue in alliance with individual hospital and institution, initiative of preparing medical policy data at a national level will be accelerated.

#operation classification code #rate of operation code

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