摘要
目的分析探讨某院诊断ICD-10分类具有C76编码的病案,查找错误编码并归纳原因,以此提高编码准确率。方法检索某院2013年-2022年疾病编码包括C76的出院病案306例,以ICD-10分类原则为依据,通过对C76编码情况进行逐份核查,统计错误率并进行分析。结果在306份病案中,编码员疾病编码错误率为98.69%。其中编码员未按照肿瘤编码原则查找编码导致错误81.79%;编码员临床医学基础知识不足占13.24%;医师诊断不明确的错误占4.97%。结论导致疾病编码错误分类于C76的主要原因是由于编码员未按照肿瘤编码规则以及未仔细查阅病理报告所导致的。因此,编码员应提高自身综合素质,有效建立与临床医师的沟通渠道,以及科室应完善质控工作,才能有效提高编码准确率。
Objectives This study aims to analyze and explore the cases with C76 codes in a hospital,find the wrong codes and summarize the reasons,so as to improve the coding accuracy rate.Methods 306 discharged medical records from a hospital from 2013 to 2022 with disease codes including C76 were retrieved.Based on the ICD-10 classification principles,the C76 coding situation was checked case by case and the error rate was counted and analyzed.Results Among 306 medical records,the coders’disease coding error rate was 98.69%.Among them,81.79%of the errors were caused by the coders'failure to search for codes according to the tumor coding principles,13.24%of the errors caused by the coders'insufficient basic knowledge of clinical medicine,and 4.97%of the errors caused by unclear diagnosis by doctors.Conclusions The main reasons leading to the misclassification of disease coding as C76 were due to the coders'failure to follow the rules of oncology coding as well as their failure to carefully review the pathology reports.Hence,coders should enhance their comprehensive skills,establish effective communication channels with clinicians,and enhance departmental quality control efforts to improve coding accuracy effectively.
作者
林佩珊
陈彩霞
李良景
任文宁
Lin Peishan;Chen Caixia;Li Liangjing;Ren Wenning(Medical Record Management Department of Shenzhen People's Hospital,Shenzhen 518001,Guangdong Province,China;不详)
出处
《中国病案》
2024年第7期34-36,共3页
Chinese Medical Record
