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Journal of Korean Society Quality Assurance Health Care 2006;12(1): 104.
Published online May 30, 2006.
사용자 수술명과 수술분류 code (ICD-9-CM) 일치율 향상에 관한 연구 (수술실 OCS program 사용 활성화를 통하여)
최향하1, 김미영2, 김도진3, 유지원1, 장정화1, 박수정4, 박재성2
1순천향대학교 부천병원 의무기록팀
2순천향대학교 부천병원 QI실
3순천향대학교 부천병원 호흡기알레르기내과
4순천향대학교 부천병원 수술실
Study of matching user operation name and operation classification code (ICD-9-CM) (Through OCS program use facilitation at operating room)
Hyang-Ha Choi1, Mi-Young Kim2, Do-Jin Kim3, Ji-Won Yu1, Jung-Hwa Chang1, Su-Jung Park4, Jae-Sung Park2
1Dept. of Medical Record, Soonchunhyang University Bucheon Hospital
2Dept. of Quality Improvement, Soonchunhyang University Bucheon Hospital
3Dept. of Pulmonary Medicine, Soonchunhyang University Bucheon Hospital
4Dept. of Nurse, Soonchunhyang University Bucheon Hospital
Abstract
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.
Key words operation classification code;rate of operation code;
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