摘要
目的 分析某院乳腺癌的诊断编码及手术编码的质量,总结分析错误原因,进而提高乳腺癌编码准确率。方法 检索某院2016年1月1日-2020年12月31日主要诊断为乳腺癌的住院病案1250份,由高年资专业病案质控医师1名及从事编码工作10年以上的资深编码员2名,根据《住院病案首页数据填写质量规范(暂行)》2016版和国际疾病分类ICD-10和ICD-9-CM-3的编码规则,核查住院病案首页填写及编码质量,对编码进行审核,统计错误类型,分析错误原因。结果 检索出以乳腺癌作为主要诊断的住院病案共1250份,经核查编码错误病案182份,其中诊断部位编码错误95份,形态学编码错误64份,手术编码错误23份。住院病案首页的编码错误率为14.56%。结论 临床医师书写病历时应注意写明乳腺癌具体发病部位,具体病理分型及手术方式,编码员应仔细阅读病案,熟悉乳腺癌的组织学分类以及常用手术术式,加强对临床知识和编码知识的学习,根据病理结果,提高编码准确率。
Objectives To analyze the quality of the diagnostic coding and surgical coding of breast cancer in a hospital,summarize and analyze the reasons for the error,and then improve the accuracy of breast cancer coding.Methods To search 1250 medical records mainly diagnosed as breast cancer from January 1 st,2016 to December 31 st,2020.In this scope,1 senior professional medical record quality control physician and 2 senior coders who have been engaged in coding work for more than 10 years were selected to fill in quality specifications according to the front page data of inpatient medical records(provisional).The coding rules of the 2016 edition and ICD-10 and ICD-9-CM-3 of the International Classification of Diseases were verified,the writing and coding quality of the front page were checked,the codes of the retrieved medical records were audited,the types of errors were counted,and the causes of errors were analyzed.Results A total of 1250 inpatient cases with breast cancer as the main diagnosis were retrieved,and 182 cases with coding errors were verified,including 95 cases with coding errors of diagnostic sites,64 cases with coding errors of morphology,and 23 cases with coding errors of surgery.The error rate of the front page of inpatient medical records was 14.56%.Conclusions When writing the medical records,clinicians should note the specific location of breast cancer,specific pathological classification and surgical method.Coders should read the medical record carefully,be familiar with the histological classification and common surgical methods of breast cancer,strengthen the study of clinical knowledge and coding knowledge,and improve the coding accuracy according to the pathological results.
作者
赵瑞
盛春蕊
侯春超
赵娴
高捷音
芦淼
邢瑶
冯雪
Zhao Rui;Sheng Chunrui;Hou Chunchao;Zhao Xian;Gao Jieyin;Lu Miao;Xing Yao;Feng Xue(The Third Affiliated Hospital of Beijing University of Chinese Medicine,Beijing 100029,China;不详)
出处
《中国病案》
2022年第6期44-46,共3页
Chinese Medical Record
基金
北京市中医病案质控中心。
关键词
乳腺癌
疾病编码
形态学编码
手术编码
Breast cancer
Disease coding
Morphological coding
The operation code
