摘要
目的 对某医院3年312例膀胱癌患者ICD编码常见错误进行分析,提高编码准确率。方法 选择某院2018年6月30日-2021年6月30日泌尿外科,疾病诊断编码为C67的312份住院病案,依据ICD编码规则进行分析,通过阅读每份病案的手术记录、病理报告、住院病案首页、出入院记录等资料,核查每份病案中临床医师手术资料填写情况及编码员疾病编码和手术编码情况,并进行分析汇总。结果 在312份病案中,疾病诊断编码错误份数是28份,病理编码错误12份,手术操作编码错误26份,疾病编码错误最多的是膀胱癌疑诊错编为C67,占疾病编码错误的42.86%,病理编码错误最多的是非肌层浸润性乳头状尿路上皮癌错编码为非侵袭性乳头状尿路上皮癌,占病理编码错误的41.67%,手术编码中较为常见的错误是回肠膀胱通道术和回肠代膀胱术混淆,占手术编码错误的19.23%。结论 提高膀胱癌ICD编码的准确率,要阅读病理报告和影像报告,明确病理性质和肿瘤部位,对于有手术的患者,认真阅读手术记录,明确膀胱癌的切除范围,从而得到正确的疾病编码和手术编码。
Objective The common errors of ICD coding in 312 bladder cancer patients in a hospital were analyzed to improve the coding accuracy. Methods From June 30th, 2018 to June 30th, 2021, 312 inpatient medical records with disease diagnosis code C67 in the department of urology of a hospital were selected and analyzed according to ICD coding rules. By reading the surgical records, pathological reports, front pages, and summary of admission and admission of each medical record, Verify the clinical surgeon’s operation information and the coders’ disease code and operation code in each medical record, and analyze and summarize. Results Among 312 medical records, there were 28 cases of disease diagnosis coding errors, 12 cases of pathological coding errors and 26 cases of surgical operation coding errors. The most disease coding errors were bladder cancer suspected miscoding as C67, accounting for 42.86% of disease coding errors. Non-muscular-invasive papillary urothelial carcinoma was most miscoded as non-invasive papillary urothelial carcinoma, accounting for 41.67% of pathological coding errors. The more common mistake in surgical coding was the confusion between ileal bladder passage and ileal bladder replacement, accounting for 19.23% of surgical coding errors. Conclusions To improve the accuracy of bladder cancer coding, it was necessary to read the pathological report and image report to clarify the pathological nature and tumor location. For patients undergoing surgery, carefully read the surgical records to clarify the scope of bladder cancer resection, so as to obtain the correct disease coding and surgical coding.
作者
陆田田
陆丹艳
覃华凌
钟婷婷
Lu Tiantian;Lu Danyan;Qin Hualing;Zhong Tingting(Guigang People’s Hospital,Guigang 537100,Guangxi Zhuang Autonomous Region,China)
出处
《中国病案》
2022年第8期26-28,共3页
Chinese Medical Record
关键词
膀胱癌
切除术
疾病编码
手术编码
Bladder cancer
Resection
Disease coding
Operation code
