病理诊断编码漏填写的原因分析及对策  

Cause Analysis and Countermeasures of Missing Filling in Pathological Diagnosis Coding

作　　者：彭君[1] 

机构地区：[1]武汉大学中南医院,武汉市430071

出　　处：《中国病案》2017年第10期38-40,共3页Chinese Medical Record

摘　　要：目的探讨病案首页质控方法,提高肿瘤病案编码质量。方法运用《病案首页质量检测软件》筛查出某院2016年1月1日-2016年6月30日住院病案首页主要诊断编码ICD-10为C00-D48,而病理诊断编码及病理号为空的528份病案。抽取所有纸质病案,对主要诊断编码、病理报告及病理诊断编码进行核查校正。结果 528份病案中,有477份为肿瘤病案,主要诊断编码正确率为90.34%;校正后的477份肿瘤病案中,有形态学编码即依据病理报告诊断肿瘤的有343份,占71.90%,无形态学编码即无病理诊断报告,而是依据影像学等临床诊断肿瘤的有134份,占28.09%;编码时有手术但无病理诊断报告的79份,占16.57%,79份缺失病理报告校正后主要诊断编码为非肿瘤的有16份,占20.25%。结论要加强肿瘤病案首页的质控,细化病理诊断及病理号的填写要求。Objective To explore the quality control method of medical records and improve the quality of medical record coding. Methods the main diagnostic encoding of 528 medical records front sheet between C00-D48 with the pathological diagnosis encoding and pathological number is empty in January 1, 2016 to June 30,2016 were selected by medical record quality examination software. All paper medical records were taken and the main diagnostic codes, pathological reports and pathological diagnosis codes were checked and corrected. Results Of the 528 medical records, 477 were tumor medical records, and the correct diagnosis rate was 90.34%. 477 tumor medical records after correction, which is based on the morphological encoding pathology diagnosis of tumor has 343,accounting for 71.90%. No morphological coding, no pathological diagnosis, and according to imaging and other clinical diagnosis has 134, accounting for 28.09%; There were 79 reports of surgery without pathological diagnosis,accounting for 16.57%. After the correction of 79 missing pathological reports, 16 cases were diagnosed as non tumor, accounting for 20.25%. Conclusion We should strengthen the quality control of the medical record of tumor,improve the requirements of pathological diagnosis and pathology number filling.

关 键 词：主要诊断 病理诊断 ICD-10 

分 类 号：R197.323[医药卫生—卫生事业管理]