乳腺癌患者静脉血栓ICD-10编码探讨  

Discussion of Venous Thrombosis ICD-10 Codes in Breast Cancer Patients

作　　者：路畅 王洪涛 杨晓宇 高丽娜 LU Chang;WANG Hongtao;YANG Xiayu;GAO Lina(Tianjin Medical University Cancer Institute&Hospital,National Clinical Research Center for Cancer,Tianjin Clinical Research Center for Cancer,Key Laboratory of Cancer Prevention and Treatment,Tianjin 300060)

机构地区：[1]天津医科大学肿瘤医院、国家恶性肿瘤临床医学研究中心、天津市恶性肿瘤临床医学研究中心、天津市肿瘤防治重点实验室,天津300060

出　　处：《江苏卫生事业管理》2024年第7期972-975,共4页Jiangsu Health System Management

基　　金：天津市医学重点学科(专科)建设项目(TJYXZDXK-009A)。

摘　　要：目的:对乳腺癌患者静脉血栓编码完整性和准确率进行分析,探讨常见问题,以期提高编码质量。方法:选取天津市某三级甲等肿瘤专科医院2019年1月1日-2023年8月31日期间,住院患者主要诊断编码为乳腺癌相关ICD-10编码,且住院期间诊断为静脉血栓的患者1731例。对静脉血栓相关编码存在问题进行分析,探讨改进措施。结果:401份病案静脉血栓形成编码错误,乳腺癌患者静脉血栓病案ICD-10编码错误原因主要归类为编码漏编、编码亚目分类错误、编码类目分类错误,占比分别为85.29%、12.97%、1.74%。结论:主要改进措施包括加强层级管理、开展ICD-10编码培训、病案首页质控常态化、建立评价机制、增强编码员责任心、实现首页编码复审机制、健全信息化质控手段等,以确保医师所填病案数据完整、真实、准确,切实提高病案编码质量。Objective:Analysis of the completeness and accuracy of venous thromboembolism coding in breast cancer patients,aiming to explore common issues and improve coding quality.Methods:A total of 1,731 cases of breast cancer patients with venous thromboembolism diagnosed during their hospitalization at a certain grade A tertiary oncology hospital in Tianjin between January 1,2019,and August 31,2023,were selected.The coding quality of venous thromboembolism-related ICD-10 codes was analyzed,and measures to improve it were discussed.Results:There were 401 cases of incorrect venous thromboembolism coding in the medical records.The main reasons for incorrect ICD-10 coding of venous thromboembolism in breast cancer patients were classified as omission of coding,incorrect sub-item classification,and incorrect category classification,accounting for 85.29%、12.97%、1.74%respectively.Conclusion:The main improvement measures include strengthening hierarchical management,carrying out ICD-10 coding training,normalizing the quality control of the first page of medical records,establishing an evaluation mechanism,enhancing the sense of responsibility of coders,realizing the review mechanism of home page coding,and improving the information quality control methods,etc.,to ensure that the data of medical records filled in by physicians are complete,true and accurate,and effectively improve the quality of medical record coding.

关 键 词：乳腺癌 静脉血栓 ICD-10编码 质控分析 改进措施 

分 类 号：R197.39[医药卫生—卫生事业管理]