115例交搭跨越性食管恶性肿瘤ICD-10编码分析  

ICD-10 Coding Analysis on the 115 Cases of Overlapping Therioma of Oesophagus Malignant Tumors

作　　者：邓添薪[1] 张帆[1] 满丽芳[1] 朱芳芳[1] 王君璇 廖宁[1] Deng tianxin Zhang Fan Man Lifang Zhu Fangfang Wang Junxuan Liao Ling(Department of Medical record information of The Fist Affiliated Hospital of Guangxi Medical University, Nanning 530022, Chin)

机构地区：[1]广西医科大学第一附属医院病案信息科,南宁市530022

出　　处：《中国病案》2017年第3期26-28,共3页Chinese Medical Record

基　　金：广西医药卫生自筹经费计划课题(Z2016727)

摘　　要：目的提高编码人员对交搭跨越性食管恶性肿瘤ICD-10编码的准确性及编码速度。方法在某大型三甲医院的病案首页信息系统中,检索2014年1月1日-2015年12月31日出院中主要诊断ICD-10编码为C15.8/C16.0/C26.8/C76.8的病案。通过对病案的阅读,根据《疾病和有关健康问题的国际统计分类》中的分类要求,对检索出来的115份病案的主要诊断编码进行分析。结果 115份病案中,23份首页的主要诊断编码是正确的,所占比例仅为20%,其中C15.8中错误例数最多,为75例,C16.0中错误例数为15例,两例C26.8的病例均错误。结论要提高此类编码的质量与效率,最重要的是编码人员要明确"交搭跨越"的含义,其次要明确食管的分段并仔细阅读病案,明确病变部位,与此同时,加强与临床医师的沟通及设立学科编码员亦是有效途径。Objective To improve the accuracy and speed of overlapping therioma of oesophagus malignant tumors in the coding. Methods From a information system in the front pages of medical record to retrieve from January 1st 2014 to December 31 st 2015, the primary diagnosis encoding with C15.8/C16.0/C26.8/C76.8 of the medical records. And then analyzed the primary diagnosis code of 115 medical records through reading of medical records,according to requirements of ICD-10 International Statistical Classification of Diseases and Related Health Problems. Results In 115 copies of medical records, medical records of correctness in the code of a total of 23 samples, the accuracy rate was 20%. In which C15.8 had the most error cases of 75, C16.0 had the least error cases of 15 and the two cases of C26.8 both wrong. Conclusions To improve the quality of such codes, the most important was the coding staff to clear the meaning of＂overlapping＂.Secondly we should definite the lesion by clearing the esophagus segments, read the medical record carefully and explicit the lesion site. At the same time, to strengthen the communication with clinicians and set up subject coder were also the effective ways.

关 键 词：交搭跨越 食管 恶性肿瘤 ICD-10 编码 

分 类 号：R735.1[医药卫生—肿瘤] R197.323[医药卫生—临床医学]