肿瘤化疗后骨髓抑制编码分析  

Myelosuppression coding after tumor chemotherapy

作　　者：邓梅君 李燕菁 刘丹丹 曾成力 罗坚[1] DENG Meijun;LI Yanjing;LIU Dandan;ZENG Chengli;LUO Jian(Guangdong Women’s and Children’s Hospital,Guangzhou 511400,China)

机构地区：[1]广东省妇幼保健院,广东广州511400

出　　处：《现代医院》2023年第2期221-223,共3页Modern Hospitals

摘　　要：目的 通过分析某三甲医院病案首页肿瘤化疗后骨髓抑制编码的常见错误及原因,提高肿瘤化疗后骨髓抑制编码准确性。方法 利用病案统计管理系统检索某院2019年1月1日—12月31日期间出院诊断编码中包含Z51.1或D70或D69.5或D61.1的病案,筛选出肿瘤化疗后存在骨髓抑制的病案,并分析骨髓抑制编码错误的类型及原因。结果 共611份肿瘤化疗后存在骨髓抑制的病案,其中515份编码错误,错误率达到84.3%。在错误原因分析中,错误率最高的是医师漏填写骨髓抑制相关的诊断,其次为编码员错编和漏编。结论 肿瘤化疗后骨髓抑制编码错误率高,需要临床医师规范书写首页诊断、编码员加强临床知识和编码规则的学习,以提高编码准确率。Objective To improve the accuracy of chemo-induced myelosuppression coding by analyzing the common errors and causes of myelosuppression coding on the home page of medical records in a tertiary hospital.Methods A medical case statistical management system was used to retrieve cases containing Z51.1 or D70 or D69.5 or D61.1 in the discharge diagnosis code of a hospital from January 1stto December 31st, 2019, to screen out medical records with myelosuppression after tumor chemotherapy and analyze the types and causes of myelosuppression coding errors.Results There were 611 cases of myelosuppression after chemotherapy, of which 515 were coded incorrectly, with an error rate of 84.3%. By analysing the errors, it was found that the most causes were the physician’s omission to fill in the diagnosis related to myelosuppression, followed by the coder’s miscoding and omissions.Conclusion The coding error rate of myelosuppression after tumor chemotherapy is high. Therefore, clinicians must standardize the writing of home page diagnoses, and coders should improve their clinical knowledge and coding rules, so as to improve coding accuracy.

关 键 词：骨髓抑制 肿瘤 化疗 ICD-10 

分 类 号：R197.323.1[医药卫生—卫生事业管理]