胃肠道间质瘤形态学编码分析  

Morphological Coding Analysis of Gastrointestinal Stromal Tumors

作　　者：李丽[1] 钟雪梅[1] 

机构地区：[1]中国医学科学院肿瘤医院,北京市100021

出　　处：《中国病案》2015年第3期29-30,37,共3页Chinese Medical Record

摘　　要：目的提高胃肠道间质瘤形态学编码的准确率。方法利用医院病案管理系统检索出某院1999年1月1日至2014年10月31日病理诊断为间叶源性肿瘤839例,以《国际疾病分类肿瘤学专辑》为工具书,回顾性分析某院近16年病理报告中"间叶源性肿瘤"的编码情况,对存在的问题进行汇总分析。结果因病理诊断技术受限诊断为"平滑肌肉瘤"的有59例,占7.03%;因肿瘤发生部位不同,分类编码不准确的有184例,占21.93%;因编码员对肿瘤评估指标不熟悉,分类编码不准确的有101例,占12.04%。结论编码人员必须仔细阅读病理报告.遇到问题主动与临床、病理医生沟通,还应严格把握疾病分类编码的质量关,提高责任心,才能提高胃肠道间质瘤编码的准确性。Objective To enhance the accuracy of morphological coding of gastrointestinal stromal tumors.Methods 839 cases whose pathological diagnosis were gastrointestinal mesenchymal tumors were searched out with the application of the medical records management system of the hospital from 1st January in 1999 to 31 st October in 2014.then conduct a retrospective analysis on the coding situations of the pathological reports with ＂gastrointestinal mesenchymal tumors＂ in the nearly 16 years of the hospital. as well as make summary and analysis on the existing problems. Results There were 59 cases diagnosed with ＂leiomyosarcoma＂ because of the limitation of pathological diagnosis technology. which accounted for 7.03%. 184 cases with inaccurate classification coding.which accounted for 21.93%. and 101 cases with inaccurate classification coding because of the unfamiliar with tumors assessment indicators of the coders. which accounted for 12.04%. Conclusions The coders must read the pathological report carefully. and communicate with clinical and pathological doctors actively when encounter problems. and should also be strictly grasp the quality of disease classification coding as well as improve the sense of responsibility. so as to improve the accuracy of gastrointestinal stromal tumor coding.

关 键 词：胃肠道间质瘤 形态学编码 病理诊断 

分 类 号：R735[医药卫生—肿瘤]