利用病理信息系统复核病案首页结肠癌编码的实践与探讨  

Practice and Discussion on Preliminary Review of Colon Cancer Coding in Medical Record Homepage by Using Pathological Information System

作　　者：朱京京 尹瑞华 葛琛阳 胡斌 王小红[2] 单前 何国斌 郑红娟 凌丽仙 傅健飞[1] ZHU Jing-jing;YIN Rui-hua;GE Chen-yang;HU Bin;WANG Xiao-hong;SHAN Qian;HE Guo-bin;ZHENG Hong-juan;LING Li-xian;FU Jian-fei(The Affiliated Jinhua Hospital,Zhejiang University School of Medicine;Centers for Disease Control andPrevention of Jinhua)

机构地区：[1]浙江大学医学院附属金华医院 [2]金华市疾病预防控制中心

出　　处：《医院管理论坛》2022年第10期94-96,93,共4页Hospital Management Forum

基　　金：浙江省自然科学基金项目一般项目,编号:LY19H160020-1;浙江省公益基金研究项目社会发展领域项目,编号:LGF18H160029-1;金华市科技计划项目公益类项目,编号:2019-4-008;金华市中心医院中青年科研启动基金,编号:JY2018-2-14。

摘　　要：目的探讨利用病理信息系统前置复核病案首页结肠癌编码准确性。方法利用医院病理信息系统中患者结肠癌信息与医院病案首页编码信息进行匹配,通过韦恩图分析两个系统之间结肠癌诊断匹配准确性,探讨病案首页中结肠癌ICD-10编码存在的问题。结果病案首页系统共筛查出1148例结肠癌患者,病理信息系统筛查出1060例患者,韦恩图分析发现232(19.0%)例患者诊断信息不匹配,40(3.3%)例患者编码错误。结论病理信息系统前置复核有助于改进病案首页中结肠癌编码的准确性。Objective To discuss the accuracy of colon cancer coding in medical record homepage by means of preliminary review in pathological system.Methods The colon cancer information were matched between pathological system and medical record homepage and the accuracy of the two systems was analyzed by Venn diagram.Problems in the International Classification of Colonic Diseases(ICD-10)coding in medical record homepage were discussed.Results A total of 1148 patients with colon cancer were enrolled from the medical record homepage coding system,and 1060 patients were enrolled from the pathological system.232(19.0%)patients were unmatched and 40(3.3%)patients had coding errors according to Venn diagram analysis.Conclusion Preliminary review of pathological system is conductive to improving the accuracy of colon cancer coding in medical record homepage.

关 键 词：病案首页 ICD-10 疾病诊断 结肠癌 前置审核 

分 类 号：R197.3[医药卫生—卫生事业管理]