恶性肿瘤疾病编码错误的原因分析与对策

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关键词：恶性肿瘤；疾病编码；主要诊断

中图分类号：R197.323 文献标志码：A 文章编号：1001-5779（2025）09-0892-05

DOI：10. 3969/j.issn.1001-5779.2025.09.013

Abstract：Objective：To analyze coding erors inmalignant neoplasmsand tumor morphology，and propose strategies to improvecodingaccuracy.Methods：Aretrospectivereview wasconductedon 655cases of primary malignant tumors dischargedfromahospital betweenJanuary1，2023andDecember31，2O23.The hospital'sinpatient medicalrecord frontpage management systemwasutilizedtoretrieve data，andseniormedicalcodersfrom the medicalrecords department performed one-to-oneaccuracyverification.Typicalcoding erorcases werecategorized，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，and2cases（ 7.14% ）stemmed from inadequate communication with clinical andpathology departments wereattributed toother coding erors.Conclusion：Non-standard diagnosis documentation byclinicians，insufficient clinicalandpathological knowledge amongcoders，failuretostayupdated withthelatest WHOclassificationsof tumor morphology，lack ofcommunication withclinical and pathologydepartments，inadequate masteryof tumorcoding rules， andinsufficentawarenessand sensitivitytochangesintumorclassficationstandardsarethemaincausesoferosin malignanttumorcoding.Enhancing trainingand qualitycontrol inmalignanttumordiagnosis documentationand disease coding，along with establishingcommunication mechanisms with clinicaland pathology departments，are key to improving the accuracy of malignant tumor coding.

Keywords：Malignant tumor；Disease coding；Main diagnosis

恶性肿瘤是导致人类死亡的主要疾病之一，严重危害人类健康，已成为我国乃至世界的一个主要公共卫生问题[。（剩余5895字）