恶性肿瘤疾病编码错误的原因分析与对策OA

Objective:To analyze coding errors in malignant neoplasms and tumor morphology,and propose strategies to improve coding accuracy.Methods:A retrospective review was conducted on 655 cases of primary malignant tumors discharged from a hospital between January 1,2023 and December 31,2023.The hospital's inpatient medical record front page management system was utilized to retrieve data,and senior medical coders from the medical records department performed one-to-one accuracy verification.Typical coding error cases were categorized,analyzed,and summarized to determine root causes.Results:Among 655 cases,28 exhibited coding errors(error rate:4.27%).The causes of coding errors are summarized as follows:9 cases(32.14%)were due to non-standard diagnosis documentation by clinicians,6 cases(21.43%)resulted from insufficient updates on tumor morphology by coders,5 cases(17.86%)were caused by coders'lack of mastery of coding rules,4 cases(14.29%)occurred due to coders'insufficient clinical knowledge,and 2 cases(7.14%)stemmed from inadequate communication with clinical and pathology departments were attributed to other coding errors.Conclusion:Non-standard diagnosis documentation by clinicians,insufficient clinical and pathological knowledge among coders,failure to stay updated with the latest WHO classifications of tumor morphology,lack of communication with clinical and pathology departments,inadequate mastery of tumor coding rules,and insufficient awareness and sensitivity to changes in tumor classification standards are the main causes of errors in malignant tumor coding.Enhancing training and quality control in malignant tumor diagnosis documentation and disease coding,along with establishing communication mechanisms with clinical and pathology departments,are key to improving the accuracy of malignant tumor coding.