临床医生肿瘤诊断编码错误的影响因素分析及其改进策略

目的：探讨临床医生肿瘤诊断编码错漏填写的原因和改进措施。方法：运用我院《病案首页检索系统》与《病理报告系统》结合,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-D98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：质量改进措施实施后,肿瘤诊断编码错漏例数显著低于措施实施前,具有统计学意义（P<0.05）,结论：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 and Improvement Strategies of Clinicians' Tumor Diagnosis Code Errors

Objective To explore the reasons and improvement measures for incorrect and missed filling code of clinicians in the tumor diagnosis. Methods Our hospital used the combination of "Retrieval System on the Home Page of Medical Records " and "Pathology Report System" to screen out cases with ICD-10 as C00-D98 on the hospital''s inpatient medical record home page from January 2019 to July 2019. Corresponding to check the results of the pathology report, analyzing the causes of the problems based on the correspondingly found cases of incorrect and missed filling. Then, using the same screening method, retrieve the number of errors and omissions in the tumor diagnosis code on the home page of the inpatient medical record from January 2020 to July 2020 after the hospital has formulated and implemented quality improvement measures. Results After the measures of quality were implemented, the number of tumor coding errors and omissions was significantly lower than before the measures, which has statistical significance (P<0.05). Conclusion The implementation of measures to improve the quality of clinicians'' tumor diagnosis codes can significantly improve the quality of tumor diagnosis codes.