2150例恶性肿瘤患者编码质量分析  

Analysis on the Coding Quality of 2150 Cases of Patients with Malignant Tumors

作　　者：彭城[1] 张雪梅[1] 洪英[1] 袁欣[1] 杨帆[1] 

机构地区：[1]广州军区武汉总医院质量管理科,武汉市430070

出　　处：《中国病案》2018年第1期26-28,共3页Chinese Medical Record

摘　　要：目的分析恶性肿瘤患者编码错误情况,提高恶性肿瘤编码准确性、探索改进措施。方法通过住院病案首页检索某三甲医院2015年1月-2016年12月出院患者,选取主要诊断为恶性肿瘤的病例2150例,采用双盲同行评议法审核编码错误类型与错误例数,并进行统计分析。结果 2150份病案中存在编码错误病案230例,编码错误率比例10.70%,其中部位编码错误126例,主要诊断选择错误75例,形态学编码错误29例,三种错误类型分别占比54.78%、32.61%、12.61%。结论改进管理方法、建立相关奖惩机制,加强编码员培训、与临床科室建立良好的沟通环境是提高编码正确率的有效对策。Objectives To analyze the coding errors of malignant tumor patients, improve the accuracy of malignant tumor coding and explore improvement measures. Methods To search the discharged patients in a Three A and Tertiary Hospital from January 2015 to December 2016 through the hospital medical record front pages, 2150 cases medical records diagnosed with malignant tumors were selected, review the coding error types and wrong cases with double-blind peer review method, and make statistical analysis. Results There were 230 incorrect coding samples in the 2150 cases, the error rate was 10.70%, of which 126 cases of parts errors, 75 cases of the main diagnostic errors and 29 cases of morphological errors, three types of errors accounted for 54.78%, 32.61% and 12.61% respectively. Conclusions The effective measures to improve the coding accuracy included improve management method, establish the related rewards and punishment mechanism, strengthen the training of coders, and establish a good communication environment with the clinical department.

关 键 词：恶性肿瘤 疾病编码 改进 

分 类 号：R197.323[医药卫生—卫生事业管理]