某三甲医院肿瘤国际疾病分类编码质量回顾性分析

doi:10.3969/j.issn.1006-5253.2022.03.06

Abstract
Figure/Table
References (0)
Related Citation (15)

Download: PDF (3262 KB) HTML (1 KB)
Export: BibTeX | EndNote (RIS)

Abstract Tumor disease coding is one of the difficulties in International Classification of Diseases (ICD) coding. With the development of DRG/DIP payment, the quality of the first page of medical records is getting more and more attention. Based on the coding rule logic of International Statistical Classification of Diseases and Related Health Problems (ICD-10) and CHS-DRG (1.0) of National Healthcare Security Administration, this study adopted a comprehensive quality control method of initial screening and manual review by quality control software. A retrospective quality control analysis was carried out on the first page diagnosis of 48 099 medical records in a tertiary hospital in Shanghai in 2020. The results showed that there were some problems in the first page of 203 medical records, such as wrong tumor location code, histomorphological coding error caused by interpreting without real understanding, hematological tumor histomorphological coding errors, and tumor coding errors caused by inadequate clinical communication or insufficient medical knowledge.

Key words： disease classification tumor coding ICD-10 retrospective analysis

Received: 29 December 2021

	Service

	E-mail this article
	Add to my bookshelf
	Add to citation manager
	E-mail Alert
	RSS
	Articles by authors
	Guo Xusheng
	Li Rengang
	Xi Yue

Cite this article:

Guo Xusheng,Li Rengang,Xi Yue. Retrospective analysis of the coding quality of International Classification of Diseases for tumors in a tertiary hospital[J]. journal1, 2022, 29(3): 188-191.

URL:

http://manu58.magtech.com.cn/Jwk_zgyytj/EN/10.3969/j.issn.1006-5253.2022.03.06 OR http://manu58.magtech.com.cn/Jwk_zgyytj/EN/Y2022/V29/I3/188

［1］陈丽君，刘毅，张德明，等．住院病案首页质量对DRGs入组率的影响［J］．中国病案，2019，20(1)：7-9．DOI:10.3969/j.issn.1672-2566.2019.01.003.
［2］陶培东，唐晓慧，贾元元．浅析3例疑难肿瘤ICD-10编码［J］．中国病案，2020，21(3)：31-33．DOI:10.3969/j.issn.1672-2566.2020.03.011.
［3］董景五．疾病和有关健康问题的国际统计分类：ICD-10:第2卷［M］．北京：人民卫生出版社，2011.
［4］国家医疗保障局办公室．国家医疗保障局办公室关于印发医疗保障基金结算清单填写规范的通知：医保办发〔2020〕20号［A/OL］．（2020-04-24）［2021-05-08］.http://www.nhsa.gov.cn/art/2020/5/8/art_37_3100.html?from=singlemessage.
［5］吴英宏，牟玉英，古莲香，等．疾病分类的唯一性与编码员的自由裁量权［J］．现代医院，2011，11(8)：141-142．DOI:10.3969/j.issn.1671-332X.2011.08.069.
［6］郑琳，林海丽．肝内外胆管恶性肿瘤的ICD编码分析［J］．中国病案，2014，15(11)：31-33．DOI:10.3969/j.issn.1672-2566.2014.11.015.
［7］潘艳芳，赵华．白血病的ICD10编码探讨［J］．中国病案，2018，19(4)：38-40．DOI:10.3969/j.issn.1672-2566.2018.04.015.
［8］陆丹艳，刘骏峰，肖晓兰，等．恶性淋巴瘤ICD-10编码探讨［J］．中国病案，2018，19(8)：34-36．DOI:10.3969/j.issn.1672-2566.2018.08.013.
［9］王玉芹，赵钦花，王振城，等. 非霍奇金淋巴瘤疾病分类编码质量分析［J］.中国病案，2017，18（10）：33-35.DOI:10.3969/j.issn.1672-2566.2017.10.012.
［10］吴妙婷，江丽凤，许萍，等．淋巴瘤的疾病分类分析［J］．中国病案，2013，14(9)：41-42．DOI:10.3969/j.issn.1672-2566.2013.09.020.
［11］李向红．WHO淋巴瘤分类简介［J］．当代医学，2009，15(14)：77-79．DOI:10.3969/j.issn.1009-4393.2009.14.019.