摘要
目的分析消化道早癌编码错误原因,提高消化道早癌编码正确率。方法通过病案检索系统以手术操作"EMR"和"ESD"为检索条件,筛选出某三甲医院2014年至2016年消化内科诊治的主要诊断为消化道早癌的病案共440例。通过查阅440例病案最终的病理结果,对消化道早癌编码的正确率进行统计分析。结果 440例消化道早癌诊断的病理分型存在较大差异,其中编码正确的为393份,正确率为89.3%。导致错误编码的主要原因:没有认真阅读病理报告,对于临床诊断和国际疾病分类原则不够理解,对于编码工作缺乏完善的质量监督制度。结论疾病分类编码人员除了要掌握疾病分类编码的理论方法,还要掌握一定的医学基础知识,熟悉解剖学、病理学及疾病诊断名称。建立完善的编码流程,在编码的过程中,通过阅读病理报告,将消化道早癌进行准确分类并加以审核。
Objective To analyze the causes of coding errors in early carcinoma of digestive tract, and to improve the correct rate of coding. Methods The medical record retrieval system in the operation of ＂EMR＂ and ＂ESD＂ as the search conditions, selected a total of 440 cases the main diagnosed as early carcinoma of digestive tract in a hospital from 2014 to 2016. By consulting the final pathological results of 440 cases of medical records, the correct rate of early carcinoma of digestive tract coding was statistically analyzed. Results There were significant differences in the pathological types of 440 cases of early digestive tract cancers, among which 393 were correctly coded, with a correct rate of 89.3%. Main causes of error encoding： Didn＇t read the pathology report carefully, insufficient understanding of clinical diagnosis and international classification of diseases, and there is no perfect quality supervision system for coding work. Conclusion The disease classification and coding personnel in addition to master the theory and method of disease classification and coding, but also master some basic medical knowledge, familiar with the anatomy, pathology and diagnosis. Establish a perfect coding process, read the pathological report, to accurately classify and audit.
作者
郝冬芳
Hao Dongfang(Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China)
出处
《中国病案》
2017年第12期39-41,共3页
Chinese Medical Record
关键词
消化道早癌
病理分类
ICD
编码
Early carcinoma of digestive tract
Pathological Classification
ICD
Coding
