临床医生肿瘤诊断编码填写准确性影响因素分析:基于上海市某三级甲等综合性医院的实证研究

目的:基于上海市某三级甲等综合性医院的临床数据,分析临床医生肿瘤诊断编码填写准确性的影响因素,探讨有效的应对策略及实证效果。方法:结合我院《病案首页检索系统》与《病理报告系统》,筛查出2019年1月至2019年7月医院住院病案首页中主要诊断ICD-10编码为C00-D48的病例,并对应核查病理报告结果,根据对应发现的肿瘤诊断编码错漏病例,分析问题产生的原因,用同样的筛查方式,检索医院制定并实施质量改进措施后2020年1月至2020年7月住院病案首页中肿瘤诊断编码错漏例数。结果:2019年1月至7月,共采集12 382份病例,其中存在病理诊断编码错漏的病例有2 712份,错漏率在21.92%。2020年1月至7月11 872份病例中,错漏病例为1 272份,错漏率在10.70%,两组间差异有统计学意义(P0.05),肿瘤诊断编码错漏率低于改进前,改善幅度11%。2019年病例数中,临床编码原则错误、病理结果不确定以及病理报告时间滞后产生的错漏合计为2 712份,分别占病例统计总量的12%、6%、4%。2020年因临床编码原则错误、病理结果不确定及病理报告时间滞后产生错误的情况都出现较明显的改善(P0.05)。其中,临床编码原则错误率减少了7%,因病理结果不确定、病理报告时间滞后产生错误率分别减少了3%、2%。结论:基于上海市某三级甲等综合性医院的实证研究数据表明,通过对临床医生肿瘤诊断编码质量的一系列改进措施实施,能明显提高肿瘤诊断编码的质量。

Analysis of influencing factors affecting the accuracy of clinician's tumor diagnosis code filling: an empirical study based on data of a tertiary general hospital in Shanghai

Objective: To explore the reasons and improvement measures for incorrect and missed filling code of clinicians in the tumor diagnosis. Methods: Based on the combination of "Medical Record Home Page Retrieval System" and "Pathology Report System", we screened out the cases with ICD-10 code C00-D48 on the home page of hospital medical records from January 2019 to July 2019, checked the results of pathology report correspondingly, analyzed the causes of the problems according to the cases with errors and omissions in tumor diagnosis codes found correspondingly, and then screened by the same method after quality improvement measures were formulated and implemented (from January 2020 to July 2020). Results: From January to July, 2019, a total of 12 382 cases were collected, of which 2 712 (21.92%) cases had errors and omissions in pathological diagnosis codes. From January to July, 2020, among the 11 872 cases, there were 1 272 (10.70%) cases with errors and omissions. The difference between the two groups was statistically significant (P<0.05). The error and omission rate of tumor diagnosis code was lower than that before improvement, and the improvement rate was 11%. In 2019, there were 2 712 errors and omissions caused by errors in clinical coding principles, uncertain pathological results, and delayed pathological reporting time, accounting for 12%, 6%, and 4% of the total cases, respectively. In 2020, the cases caused by the error of clinical coding principle, uncertain pathological results, and delayed pathological reporting time all showed obvious improvement (P<0.05). Among them, the error rate of clinical coding principle decreased by 7%, and the error rates caused by uncertain pathological results and delayed pathological reporting time decreased by 3% and 2% respectively. Conclusions: Through a series of quality improvement measures, the quality of tumor diagnosis coding can be obviously improved.