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目的:研究广州医科大学附属肿瘤医院肿瘤形态学编码上出现的问题及应对的措施。方法:全面系统性的对广州医科大学附属肿瘤医院2012年10月至2015年10月肿瘤的临床诊断和形态学编码等情况进行调研。分析讨论出现的各种问题,汇总和探讨应对的对策。结果:由肿瘤的病理诊断报告可知,本院医务人员打印的报告不合格或者没有及时填写的共1799份,不合格率约占15.97%。肿瘤的形态学编码比较,存在不精准或者遗失的共有485份,不合格率在4.31%左右。结论:对肿瘤形态学编码进行严格的规范和分类,注重医务人员专业知识的普及,增强他们的责任心和使命感,在一定程度上通过现代信息化设备,逐步实现肿瘤形态学编码上的科学性和准确性。
OBJECTIVE: To study the problems that appear in the tumor morphology coding of Affiliated Tumor Hospital of Guangzhou Medical University and the countermeasures. Methods: A comprehensive and systematic investigation of the clinical diagnosis and morphological coding of tumors in the Affiliated Tumor Hospital of Guangzhou Medical University from October 2012 to October 2015 was conducted. Analysis and discussion of the various problems that arise, summary and discussion of countermeasures. Results: According to the pathological diagnosis report of the tumor, 1799 copies of the report printed or not filled in time by medical staff in our hospital were found, accounting for 15.97% of the total. Cancer morphological coding comparison, there are not accurate or missing a total of 485 copies, the failure rate of about 4.31%. Conclusion: Strictly regulate and classify the morphological coding of the tumor, pay attention to the popularization of the professional knowledge of the medical staff and enhance their sense of responsibility and mission. To a certain extent, through the modern informationization equipment, gradually realize the science of tumor morphology coding Sexuality and accuracy.