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目的提高胃肠道间质瘤形态学编码的准确率。方法利用医院病案管理系统检索出某院1999年1月1日至2014年10月31日病理诊断为间叶源性肿瘤839例,以《国际疾病分类肿瘤学专辑》为工具书,回顾性分析某院近16年病理报告中“间叶源性肿瘤”的编码情况,对存在的问题进行汇总分析。结果因病理诊断技术受限诊断为“平滑肌肉瘤”的有59例,占7.03%;因肿瘤发生部位不同,分类编码不准确的有184例,占21.93%;因编码员对肿瘤评估指标不熟悉,分类编码不准确的有101例,占12.04%。结论编码人员必须仔细阅读病理报告.遇到问题主动与临床、病理医生沟通,还应严格把握疾病分类编码的质量关,提高责任心,才能提高胃肠道间质瘤编码的准确性。
Objective To improve the accuracy of morphological coding of gastrointestinal stromal tumors. Methods A total of 839 patients with mesenchymal tumors diagnosed in a hospital from January 1, 1999 to October 31, 2014 were searched using the hospital medical records management system. A retrospective analysis was carried out using the International Classification of Diseases oncology as a reference book A hospital nearly 16 years pathological report “mesenchymal tumor” encoding situation, the existing problems are summarized analysis. Results of pathological diagnosis of limited diagnosis of “leiomyosarcoma” in 59 cases, accounting for 7.03%; due to the different parts of the tumor, classification coding is not accurate in 184 cases, accounting for 21.93%; due to the coding of tumor assessment indicators Not familiar with the classification coding is not accurate in 101 cases, accounting for 12.04%. Conclusion The coder must carefully read the pathology report.When encountering problems actively communicate with the clinicians and pathologists, we should also strictly grasp the quality of disease classification and coding and improve the sense of responsibility in order to improve the accuracy of gastrointestinal stromal tumor coding.