模块化疾病编码与手术操作分类体系的构建及在病案管理中的研究

Objective To develop a modular International Classification of Diseases(ICD) coding and surgical procedure classification system, and evaluate its application in quality control and refined management of hospital discharge abstracts. Methods The coding knowledge was divided into six modules: standard terminology, disease semantics, surgical procedure semantics, rule-based knowledge, version mapping, and quality control analysis. A closedloop workflow was established, including “preliminary review by physicians-final coding by coders-reverification for high-risk cases—feedback on results.” A before-and-after comparative study was conducted, with 2,000 hospital discharge records randomly selected before and after implementation for double-blind verification, and 500 records each were sampled to compare coding time. Results After implementation, the accuracy rates for primary diagnosis selection, disease coding, primary surgery selection, surgical procedure coding, completeness, logical consistency, and Diagnosis-Related Group(DRG) assignment reached 98.40%, 97.85%, 98.10%, 97.20%, 97.55%, 98.30%, and 97.30%, respectively, all significantly higher than before implementation(P<0.05). The average coding time per record decreased from(8.74±2.05) minutes to(5.26±1.41) minutes. Conclusion The modular system promotes early quality control intervention, improves coding quality and efficiency, and enhances data maintainability, interpretability, and traceability, providing a unified foundation for disease management, performance monitoring, and DRG/DIP data governance.