摘要
目的通过分析某三甲医院多原发恶性肿瘤的编码质量,找出存在的问题,提高多原发恶性肿瘤的编码准确率。方法收集某三甲医院2021年6月1日—2023年6月30日出院诊断含有ICD-10编码C97的病案393份,通过详细阅读病案,分析多原发恶性肿瘤C97编码容易出错的原因。结果393份病案中,34份存在C97编码错误,其中将交搭跨越恶性肿瘤错误编码至多原发恶性肿瘤11份,将同一器官系统中不相邻部位病理类型相同的恶性肿瘤错误编码至多原发恶性肿瘤9份,将远处转移或局部侵犯错误编码至多原发恶性肿瘤7份,将良性肿瘤当成恶性肿瘤导致编码错误4份,恶性肿瘤疑诊当成确诊编码3份。结论要提高C97编码的质量与效率,编码员需明确多原发恶性肿瘤的定义,认真完整地阅读病案资料,明确肿瘤的部位和病理类型,加强与临床医师的沟通。
Objective To analyze the coding quality of multiple primary malignant tumors in a tertiary hospital,identify existing problems,and improve the accuracy of coding for multiple primary malignant tumors.Methods We collected 393 medical records from a tertiary hospital from June 1,2021,to June 30,2023,with ICD-10 code C97 for the discharge diagnosis.By carefully reading the medical records,we analyzed the reasons for coding errors in multiple primary malignant tumors with code C97.Results Among the 393 medical records,there were 34 cases with coding errors in C97,including 11 cases where metastatic malignant tumors were erroneously coded as multiple primary malignant tumors,9 cases where malignant tumors of the same organ system with non-adjacent sites and the same histological type were erroneously coded as multiple primary malignant tumors,7 cases where distant metastasis or local invasion was erroneously coded as multiple primary malignant tumors,4 cases where benign tumors were mistakenly coded as malignant tumors,and 3 cases where suspected malignant tumors were coded as confirmed cases.Conclusion To improve the quality and efficiency of C97 coding,coders need to have a clear understanding of the definition of multiple primary malignant tumors,read the medical records carefully and completely,determine the location and histological type of the tumors accurately,and strengthen communication with clinical physicians.
作者
胡颖辉
孔德莹
左煌
闫学丽
HU Yinghui;KONG Deying;ZUO Huang;YAN Xueli(The First Affiliated Hospital of Xi’an Jiaotong University,Xi’an 710061,China)
出处
《现代医院》
2024年第7期1048-1050,1054,共4页
Modern Hospitals
基金
陕西省自然科学基础研究计划(S2023-JC-QN-1422)。
关键词
多原发恶性肿瘤
病案质控
ICD-10
疾病编码
Multiple primary malignant tumors
Medical record quality control
ICD-10
Disease coding
作者简介
通信作者:闫学丽,xueliy@xjtu.edu.cn。
