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| Analysis of the Coding in Ophthalmology Disease Diagnosis and Operation |
| Dalian Friendship Hospital，Dalian 116001，China |
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Abstract Objective：To check the code of the ophthalmology disease diagnosis and surgical operation in our hospital and to find the root cause of coding errors. Method：238 copies of medical records admitted to the Department of Ophthalmology in our hospital from January 2011 to December 2012 were checked in random sampling method， review of
the diagnosis and surgical operation coding was analysis in medical record.Result：In main diagnosis coding： 6 cases of disease diagnosis choice were wrong， error rate 2.5%； 18 cases disease diagnosis were uncompleted， the error rate 7.6%；7 cases of coding were error， error rate 2.9%.In operation coding：5 cases of surgical operation code were error， error rate 2.1%；10 cases of coding were omission duo to the operating omissions， error rate 4.2%.Conclusion：To achieve the correct code，clinicians should enhance training in coding knowledge，fill in the disease diagnosis and operation names accurately and standard；coders should strengthen learning and should have the good habit of reading medical records，communicating with clinicians usually，coding medical records in accordance with the principles of coding.
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