某院肺部肿瘤的诊断及手术编码质量分析  

Diagnosis of Lung Tumors in a Hospital and Analysis of the Quality of Surgical Codes

作　　者：赵硕[1] 张丽[1] 王肖然[1] 张潇 吕方[1] Zhao Shuo;Zhang Li;Wang Xiaoran;Zhang Xiao;Lv Fang(Medical Records Statistics Department,Xuanwu Hospital,Capital Medical University,Beijing 100053,China;不详)

机构地区：[1]首都医科大学宣武医院病案统计科,北京市100053

出　　处：《中国病案》2021年第8期17-20,共4页Chinese Medical Record

摘　　要：目的分析某院肺部肿瘤进行手术操作的诊断编码及手术编码的质量,查找易发生错误的编码,归纳错误原因,从而提高肺部肿瘤编码准确率。方法检索2019年1月1日至2019年12月31日主要诊断为肺部肿瘤且进行手术操作的病案851份,在该范围内由资深编码员和质控医师根据编码原则与病案资料,对检索出的病案编码进行审核,查找包括错编、漏编、多编等质量缺陷。结果以肿瘤作为主要诊断进行手术操作的病例共851份,其中主要诊断编码错误28份,漏编其他诊断31份,多编其他诊断9份。主要手术或操作编码错误25份,多编错误9份,漏编25份,住院病案首页的编码错误率约为14.92%。结论肺部肿瘤因病理分型复杂,手术方式多样容易错误编码,编码员应仔细阅读病案,熟悉肺部肿瘤的组织学分类,以及常用手术术式,加强对临床知识和编码知识的学习,及时查看病理,定期检查编码并修改,提高编码的准确率。Objective The diagnostic codes and the quality of surgical codes for lung tumors in a hospital were analyzed,the codes prone to errors were found,and the causes of errors were summarized,so as to improve the coding accuracy of lung tumors.Methods A total of 851 medical records mainly diagnosed as lung tumors and operated from January 1,2019 to December 31,2019 were searched.In this range,senior coders and quality control doctors examined the medical record codes according to the coding principles and medical record data.To look for quality defects such as miscoding,missing coding,multi-editing and so on.Results A total of 851 cases underwent surgical operation with tumor as the main diagnosis,including 28 main diagnostic coding errors,31 missed other diagnoses and 9 other diagnoses.There were 25 coding errors in major operations or operations,9 multiple errors and 25 omissions.The coding error rate on the first page of the medical record was about 14.92%.Conclusion Due to the complex pathological classification and various surgical methods,the coders should read the medical records carefully,be familiar with the histological classification of lung tumors and the common surgical procedures,and strengthen the study of clinical knowledge and coding knowledge.check the pathology in time,check the code and modify it regularly,and improve the accuracy of the code.

关 键 词：肺部肿瘤 形态学编码 手术编码 ICD 编码 

分 类 号：R197.323[医药卫生—卫生事业管理]