摘要
目的分析某三甲专科医院胸腺上皮性肿瘤形态学编码错误原因,提高胸腺上皮性肿瘤编码的准确性。方法从某院病案信息系统调取2020年1月1日-2020年12月31日出院的主要诊断ICD-10编码为C37、D15.0、D38.4,且病理诊断为上皮性肿瘤的病案共366例,根据ICD-10和WHO胸腺肿瘤分类规则,对每一份病案的编码进行核对,并对错误编码的类型进行分类。结果366份病案中有163份编码错误,错误率达44.54%,其中错误较多的病理诊断为AB型胸腺瘤(9.56%)、B1型胸腺瘤(5.19%)、B2型胸腺瘤(8.20%)、B3型胸腺瘤(6.28%)及鳞状细胞癌(8.74%)。编码错误的类型中占比较高的为编码员错误(54.60%)及临床医师错误(39.88%)。结论胸腺上皮性肿瘤形态学编码的错误率较高,编码员专业水平及态度、编码库的更新速度都影响编码正确性,因此提高胸腺上皮性肿瘤形态学编码质量,需提升编码员的业务水平及加强与临床医师的沟通。
Objectives This study aims to analyze the causes of morphological coding errors in thymic epithelial tumors in a Grade-3 specialty hospital to improve the accuracy of thymic epithelial tumor coding.Methods A total of 366 medical records which had the main discharge diagnostic ICD-10 codes of C37,D15.0,and D38.4,and were pathologically diagnosed as epithelial tumors from a hospital from January 1,2020 to December 31,2020 were retrieved from the hospital medical record information system.The morphological coding errors of thymic epithelial tumors were checked,and the types of coding errors were classified according to ICD-10 and WHO thymic tumors classification rules.Results Among the 366 medical records,there were 163 coding errors,and the error rate was 44.54%.The pathological diagnoses with more errors were type AB thymoma(9.56%),type B1thymoma(5.19%),type B2 thymoma(8.20%),type B3 thymoma(6.28%),and squamous cell carcinoma(8.74%).The most common types of coding errors were coder error(54.60%)and clinician error(39.88%).Conclusions The error rate of morphological coding of thymic epithelial tumors was relatively high.The professional level and attitude of the coders and the update speed of the coding database affect the correctness of coding.Therefore,it is necessary to improve the professional level of coders and strengthen communication with clinicians in order to improve the morphological coding quality of thymic epithelial tumors.
作者
荣雯雯
汪刚
李躲
朱蕾
Rong Wenwen;Wang Gang;Li Duo;Zhu Lei(Statistical Center,Shanghai Chest Hospital,School of Medicine,Shanghai Jiao Tong University,Shanghai 200030,China;不详)
出处
《中国病案》
2022年第11期21-23,共3页
Chinese Medical Record
基金
上海市医院协会医院管理研究基金病案云服务平台的研究(Q2021057)。
作者简介
通信作者:李躲。
