描述程序代码和医疗记录之间的一致性 退伍军人卫生管理局中文本 手术笔记
Samuel M Schut1, Sarah E Graham2, Anna R Sites3
1Department of Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, Ohio; Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine, Cleveland, Ohio.
Journal of manipulative and physiological therapeutics
|September 29, 2025
概括
退伍军人卫生管理局的手术治疗显示了当前程序术语 (CPT) 代码和记录的程序之间的高度一致性. 然而,仅仅使用CPT代码存在局限性,特别是在患者教育方面.
科学领域:
- 整形外科的护理 整形外科的护理
- 医疗信息学 医疗信息学
- 医疗保健编码系统 医疗保健编码系统
背景情况:
- 准确的编码对于医疗补偿和质量评估至关重要.
- 了解程序代码与临床文档之间的协调对于医疗保健系统至关重要.
研究的目的:
- 评估当前程序术语 (CPT) 代码与退伍军人卫生管理局 (VHA) 内的手术笔记中治疗程序的文本文档之间的一致性.
主要方法:
- 一个手动图表审查1000个随机抽取的VHA手术诊所从2017年至2018年.
- 提取CPT代码和文档程序,不包括评估和管理代码.
- 应用一种新的评级系统来评估一致性,并进行分析,包括或不包括患者教育代码.
主要成果:
- 分析了808个包含的笔记,发现了高的整体一致性:29.6%完全一致,63.5%部分一致.
- 从790条笔记中排除了患者教育代码,显示了51.1个百分点的完全一致性和41.4个百分点的部分一致性.
- 这些结果表明,在一般情况下,一致性很高,但突出了变化,特别是在患者教育方面.
结论:
- 在VHA中,CPT代码和手术程序文档之间的一致性通常很高.
- 该研究发现,仅依靠CPT代码来表示VHA手术护理的局限性,特别是患者教育的代表性不足.
- 编码实践的进一步完善可能是必要的,以充分捕捉提供手术服务的范围.
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