恶性肿瘤个人史分类编码存在的问题与探讨  

Problems and Discussion on Classification and Coding of Personal History of Malignant Tumors

作　　者：隗和澎 隗和红 鲁杨[3] 季新强[1] WEI He-peng;WEI He-hong;LU Yang;JI Xin-qiang(Beijing Cancer Hospital/Beijing Institute for Cancer Research/Key Laboratory of Carcinogenesis and Translational Research,Ministry of Education;The Sixth Hospital of Beijing;Capital Medical University Yanjing Medical College)

机构地区：[1]北京大学肿瘤医院暨北京市肿瘤防治研究所/恶性肿瘤发病机制及转化研究教育部重点实验室 [2]北京市第六医院 [3]首都医科大学燕京医学院

出　　处：《医院管理论坛》2024年第2期56-58,共3页Hospital Management Forum

基　　金：北京市海淀区预防医学会课题。

摘　　要：目的通过回顾总结某肿瘤专科医院恶性肿瘤个人史编码存在的问题,分析编码错误原因,为编码员更好地掌握恶性肿瘤个人史编码方法提供参考。方法检索某肿瘤专科医院2020年1月1日一2021年12月31日具有疾病诊断编码Z85的病案,依据ICD-10分类原则逐一核查,统计编码Z85使用错误的情况。结果具有编码Z85的病案共1632份,其中Z85编码使用错误共计160例,错误率为9.80%;160例错误病历中,Z85编码亚目出现错误66例,占错误病历总数的41.25%;Z85使用情况错误94例,占错误病历总数的58.75%。编码错误的原因分别为:恶性肿瘤史肿瘤部位归类错误(26.25%)、编码员滥用残余类目Z85.9(15.00%)、肿瘤处于现患状态、观察期(38.75%)、临床医师填写不规范导致编码错误(20.00%)。结论恶性肿瘤史分类复杂,使用情况复杂,编码员要避免使用残余类目,熟练掌握Z85的使用情况,多与临床医师沟通,准确进行编码。Objective By reviewing and summarizing the problems existing in the coding of personal history of malignant tumors in a cancer hospital,and analyzing the causes of coding errors,to provide reference for coders to better master the coding method of personal history of malignant tumors.Methods The medical records with diagnostic code Z85 in a cancer hospital from January 1,2020 to December 31,2021 were retrieved,and verified one by one according to the principles of ICD-10,and the errors of coding Z85 were counted.Results A total of 1632 medical records had Z85 coding,of which 160 cases were incorrectly used,with an error rate of 9.80%.Among the 160 incorrect medical records,66 cases were wrong in Z85 coding submesh,accounting for 41.25%of the total number of incorrect medical records.There were 94 cases of incorrect use of Z85,accounting for 58.75%of the total number of incorrect medical records.The causes of coding errors included wrong classification of tumor location in the history of malignant tumors(26.25%),coder abuse of residual category zZ85.9(15.00%),tumor in the current state,observation period(38.75%),and non-standard filling in by clinicians(20.00%).Conclusion The classification of malignant tumor history was complex and its use was complex.Coders should avoid using residual categories,master the use of Z85,communicate more with clinicians,and code accurately.

关 键 词：恶性肿瘤 个人史 国际疾病分类 

分 类 号：R197.3[医药卫生—卫生事业管理]