1131例乳腺癌疾病分类编码缺陷分析  

Analysis of Disease Coding Defects in 1131 Cases of Breast Malignant Tumors

作　　者：王悦 史素丽 Wang Yue;Shi Suli(Department of medical record,North China University of Science and Technology Affiliated Hospital,Tangshan 063000,Hebei Province,China;不详)

机构地区：[1]华北理工大学附属医院病案科,河北省唐山市063000

出　　处：《中国病案》2024年第11期38-40,共3页Chinese Medical Record

摘　　要：目的对某院乳腺癌疾病分类编码进行核查,分析编码缺陷原因,探讨提高乳腺癌疾病分类编码质量的方法。方法检索某院2022年1月1日-2023年12月31日出院的住院病案首页主要诊断描述为乳腺癌的所有病案共1131份。对病案首页主要诊断编码进行检查,并对错误类型和错误原因进行统计分析。结果1131例乳腺癌病案中编码缺陷为129例,编码正确率为88.59%。错误类型主要为错误使用C50亚目.9编码、错误使用C50编码、错误使用Z51编码等。错误原因依次为过分依赖编码库、编码规则掌握不够、未仔细阅读病案、临床知识欠缺、临床医师书写不规范、临床医师诊断错误、病理知识欠缺。结论乳腺癌的疾病分类编码要同时注意部位和形态学两部分。通过提高编码员专业水平、优化工作流程、建立与临床沟通途径、加强编码员与医师间相互培训、完善编码质量控制等方式提高乳腺癌编码质量。Objectives This study aims to check the disease coding of breast cancer in a certain hospital,analyze the causes of coding defects,and explore methods to improve the quality of breast cancer disease coding.Methods A total of 1,131 medical records of inpatient medical records of patients discharged from a certain hospital from January 1,2022 to December 31,2023,with the main diagnosis described as breast cancer on the front page,were retrieved.The main diagnosis codes of medical records were checked,and statistical analysis of error types and causes was performed.Results In 1131 cases of breast cancer,129 cases had coding defects,with a coding accuracy of 88.59%.The main types of errors were incorrect use of the fourth-character subdivisions of C50,incorrect use of C50,and incorrect use of Z51,etc.The causes of errors were over reliance on the coding database,insufficient mastery of coding rules,failure to read medical records carefully,lack of clinical knowledge,non-standard writing by clinicians,diagnostic errors by clinicians,and lack of pathological knowledge.Conclusions The disease coding of breast cancer should pay attention to both the location and morphology.The quality of breast cancer coding can be improved by improving the professional level of coders,optimizing working methods,establishing effective communication channels with clinical physicians,strengthening mutual training between coders and physicians,and improving coding quality control.

关 键 词：乳腺癌 编码缺陷 疾病分类编码 分析 

分 类 号：R197.323[医药卫生—卫生事业管理] R737.9[医药卫生—公共卫生与预防医学]