肿瘤编码常见错误及思路探讨  

Discussion on Common Mistakes in Tumor Coding

作　　者：涂晓贤[1] Tu Xiaoxian(Medical Record Department, Union Hospital of Fujian Medical University, Fuzhou 350001, Fujian Province, China)

机构地区：[1]福建医科大学附属协和医院病案室,福州市350001

出　　处：《中国病案》2018年第12期34-36,共3页Chinese Medical Record

摘　　要：目的分析某院肿瘤形态学诊断及疾病诊断编码情况,提高肿瘤形态学诊断及疾病诊断编码的准确性。方法通过病案管理系统随机抽取某三甲医院2017年10月1日-12月31日含有病理诊断的病案8296份,分析其中肿瘤形态学编码错误及诊断编码错误,并对错误产生原因进行归类分析,提出探讨。结果 8296份病例中,肿瘤形态学编码错误的有587份,疾病诊断编码错误的有121份,总体肿瘤编码错误率达到8.54%。结论分析肿瘤编码错误的原因,编码员不仅仅要掌握ICD-10的编码原则,还要具备一定的病理知识、临床知识,要学会阅读病理报告,不断拓宽视野,减少或者避免肿瘤编码错误率。Objective To analyze the situation of pathological morphological diagnosis coding and disease diagnosis coding in a hospital.To improve the accuracy of pathological morphological diagnosis coding and disease diagnosis coding.Methods Medical record management system was utilized to extract 8296 medical records with the pathological diagnosis in the fourth quarter of 2017 in a Third-level grade-A hospital.To analyze the pathologic diagnosis coding and disease diagnosis coding errors.Results In 8296 medical records,there were 587 existing obvious coding errors in pathological diagnosis,121 patients records’ disease diagnosis codes were not specific.The total coding error rate of tumor was 8.54%.Conclusion Coding staff should not only master coding principles of ICD-10,but also have certain knowledge of pathology and clinical knowledge,learn to read pathological reports,and wide horizons,then reduce or avoid tumor coding errors.

关 键 词：病理诊断 肿瘤编码 形态学编码 

分 类 号：R197.323[医药卫生—卫生事业管理]