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Tracy Wharton¹, Emily Hunt Costello, Alexis Peterson

¹National Network of Public Health Institutes, Washington, District of Columbia (Dr Wharton and Mss Costello, Bleser, and Bailey); and Centers for Disease Control and Prevention, Division of Injury Prevention, Atlanta, Georgia (Dr Peterson and Ms Sarmiento).

Journal of public health management and practice : JPHMP

|September 25, 2024

概括

由于时间压力和电子医疗记录 (EMR) 默认值,急诊室医生经常使用未指明的创伤性脑损伤 (TBI) 代码. 改进的培训和EMR修改可以提高TBI编码特异性.

科学领域:

医疗信息学医疗信息学
公共卫生监督公共卫生监督
创伤护理创伤护理

背景情况:

国际疾病分类 (ICD) 代码对于计费和伤害监测至关重要,包括创伤性脑损伤 (TBI).
尽管有特定的ICD-10-CM代码,但未指定的头部损伤代码仍然很普遍.
这突显了临床实践中对TBI的准确诊断编码存在差距.

研究的目的:

评估急诊室 (ED) 医生关于TBI诊断的编码行为.
确定影响TBI特定与未指定的ICD-10-CM代码选择的因素.
探索潜在的干预措施,以改善ED环境中的编码特异性.

主要方法:

进行了半结构化的视频采访,与26名美国ED医生进行了半结构化的视频采访,这些医生在诊断TBI方面有经验.
采用有目的的雪球采样策略来招募参与者.
利用专题分析来解释采访数据并识别关键编码影响.

主要成果:

出现了四个主要主题:医生培训/专业知识,诊断考虑,编码器沟通和实际建议.
医生引用了患者护理需求,时间限制,诊断不确定性和EMR默认值作为使用未指定的TBI代码的原因.
该研究确定了针对头部伤害的ICD-10-CM准确编码的特定障碍和促进因素.

结论:

ED提供者需要对文档进行增强培训,以支持针对TBI的特定ICD-10-CM编码.
电子医疗记录 (EMR) 系统的修改可以简化编码过程并提高特异性.
解决这些因素可以导致更准确的TBI监测和数据收集.

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