ESD手术患者主要诊断编码探讨  

Discussion on the Main Diagnostic Codes of Patients Undergoing ESD Surgery

作　　者：靳秀平 Jin Xiuping(Medical Record Management Department,Changzhi People’s Hospital affiliated to Shanxi Medical University,Changzhi 046000,Shanxi Province,China)

机构地区：[1]山西医科大学附属长治市人民医院病案管理科,山西省长治市046000

出　　处：《中国病案》2022年第2期46-48,共3页Chinese Medical Record

摘　　要：目的 分析某三甲医院内镜黏膜下剥离术患者住院病案首页主要诊断ICD-10编码情况,提高消化道早癌及癌前病变编码准确率。方法 检索2020年1月1日至2021年1月31日住院病案首页信息系统中手术编码为43.4107、45.4300x009、42.3305、48.3509的出院病案196份,通过对电子病历的阅读,依据国际疾病分类ICD-lO临床版3.0的分类原则,对检索出的196份病案中的疾病主要诊断编码进行分析。结果 共查出主要诊断疾病编码错误例数为37例,错误率为18.87%,漏编病理编码22份,漏编率11.22%。结论 内镜黏膜下剥离术主要是针对消化道早癌、癌前病变的微创手术,其临床诊断根据不同的病理结果、胃镜检查,对应的ICD-10编码也不同,错误率高。编码员要通过仔细阅读病历,按照编码规则进行编码,同时加强与临床医师沟通协作,不断分析错误原因并加以改进来提高编码的正确率。Objective To analyze the ICD-10 coding of patients undergoing endoscopic submucosal dissection in a third-class hospital,and to improve the coding accuracy of early cancer and precancerous lesions of digestive tract.Methods From January 1,2020 to January 31,2021,196 discharged medical records with surgical codes of 43.4107,45.4300 x009,42.3305 and 48.3509 were searched.Through reading the electronic medical records and according to the classification principle of ICD-10 Clinical Edition 3.0 of the International Classification of Diseases,the main diagnostic codes of diseases in the 196 medical records were analyzed.Results A total of 37 cases of coding errors in the main diagnostic diseases were found,with an error rate of 18.87%,22 pathological codes were omitted,and the omission rate was 11.22%.Conclusion Endoscopic submucosal dissection is mainly a minimally invasive operation for early cancer and precancerous lesions of the digestive tract.Its clinical diagnosis varies according to different pathological results and gastroscopy,and the corresponding ICD-10 code is different,and the error rate is high.Coders should read the medical records carefully,code according to the coding rules,strengthen communication and cooperation with clinicians,and constantly analyze the causes of errors and improve them to improve the correct rate of coding.

关 键 词：ESD 消化道早癌及癌前病变 ICD-10编码 质控 

分 类 号：R735[医药卫生—肿瘤]