论文部分内容阅读
目的分析继发性恶性肿瘤编码错误的原因,以便提高肿瘤编码的准确性。方法选取某医院2015年主要诊断为继发性恶性肿瘤的全部病案资料,查阅这些病案,按照ICD-10编码原则找出编码错误的原因并进行统计分析。结果 453份病案中主要诊断编码错误的有79份,错误率为17.4%。导致错误编码的主要原因是未仔细阅读病案,占72.1%;其次是编码员未掌握相应的编码原则,占27.9%;有老师带教方式培养的编码员比无带教培养的编码员的错误率更低(P=0.047)。结论加强编码员的责任心、熟练掌握恶性肿瘤的主要诊断选择编码的原则、编码员的工作量分配适当、以参加培训班加带教的方式培养编码员可以提高编码的准确性。
Objective To analyze the reasons for the wrong coding of secondary malignant tumors in order to improve the accuracy of tumor coding. Methods The data of all cases of major malignancies diagnosed in a hospital from 2015 to 2015 were selected. The medical records were consulted and the causes of coding errors were identified and statistically analyzed according to the principle of ICD-10 coding. Results Among the 453 medical records, 79 were mainly wrongly coded and the error rate was 17.4%. The main reason leading to wrong coding is not read carefully the case, accounting for 72.1%; followed by the coder did not grasp the corresponding coding principle, accounting for 27.9%; the teacher training modeler coder than the trained training error The rate was lower (P = 0.047). Conclusion Enhancing the responsibility of the coder, mastering the principle of coding the main diagnosis of malignant tumors, allocating the workload of the coder properly, and training the coders in the training courses can improve the accuracy of the code.