某三甲医院肿瘤国际疾病分类编码质量回顾性分析  

Retrospective analysis of the coding quality of International Classification of Diseases for tumors in a tertiary hospital

作　　者：郭旭升[1] 李仁刚[1] 席悦 Guo Xusheng;Li Rengang;Xi Yue(Department of Medical Record Statistics,Renji Hospital of Shanghai Jiaotong University School of Medicine,Shanghai 200127,China)

机构地区：[1]上海交通大学医学院附属仁济医院病案统计科,上海200127

出　　处：《中国医院统计》2022年第3期188-191,195,共5页Chinese Journal of Hospital Statistics

摘　　要：肿瘤疾病编码是国际疾病分类(ICD)编码中的难点之一,是编码问题出现的重灾区。随着医保疾病诊断相关分组/按病种分值付费(DRG/DIP)支付的开展,病案首页质量越来越受重视。本研究以《疾病和有关健康问题的国际统计分类(第十次修订本)》(ICD-10)的编码规则逻辑及国家医疗保障局CHS-DRG(1.0)为基础,通过质控软件初筛和人工复核的综合质控方法,对上海市某三甲医院2020年48099份肿瘤患者病案首页诊断进行回顾性质控分析。结果显示,203份病案首页存在肿瘤部位码错误、望文生义致组织形态学编码错误、血液系统肿瘤组织形态学编码错误及与临床沟通不充分或医学知识不足导致肿瘤编码错误等问题。Tumor disease coding is one of the difficulties in International Classification of Diseases(ICD)coding.With the development of DRG/DIP payment,the quality of the first page of medical records is getting more and more attention.Based on the coding rule logic of International Statistical Classification of Diseases and Related Health Problems(ICD-10)and CHS-DRG(1.0)of National Healthcare Security Administration,this study adopted a comprehensive quality control method of initial screening and manual review by quality control software.A retrospective quality control analysis was carried out on the first page diagnosis of 48099 medical records in a tertiary hospital in Shanghai in 2020.The results showed that there were some problems in the first page of 203 medical records,such as wrong tumor location code,histomorphological coding error caused by interpreting without real understanding,hematological tumor histomorphological coding errors,and tumor coding errors caused by inadequate clinical communication or insufficient medical knowledge.

关 键 词：疾病分类 肿瘤编码 ICD-10 回顾性分析 

分 类 号：R197.323[医药卫生—卫生事业管理]