Jospital医皖管理论坛MedicalManagement恶性肿瘤个人史分类编码存在的问题与探讨ProblemsandDiscussiononClassificationandCodingofPersonalHistoryofMalignantTumors陀和澎WEIHe-peng口下院和红WEIHe-hong②鲁杨LUYang3季新强JIXin-qiang摘要Abstract目的通过回顾总结某肿瘤专科医院恶性肿瘤个人史编码存在的问题，分析编码错误原因，为编码员更好地掌握恶性肿瘤个人史编码方法提供参考。方法检索某肿瘤专科医院2020年1月1日一2021年12月31日具有疾病诊断编码Z85的病案，依据ICD-10分类原则逐一核查，统计编码Z85使用错误的情况。结果具有编码Z85的病案共1632份，其中Z85编码使用错误共计160例，错误率为9.80%；160例错误病历中，Z85编码亚目出现错误66例，占错误病历总数的41.25%；Z85使用情况错误94例，占错误病历总数的58.75%。编码错误的原因分别为：恶性肿瘤史肿瘤部位归类错误(26.25%)、编码员滥用残余类目Z85.9(15.00%)、肿瘤处于现患状态、观察期(38.75%)、临床医师填写不规范导致编码错误（20.00%)。结论恶性肿瘤史分类复杂，使用情况复杂，编码员要避免使用残余类目，熟练掌握Z85的使用情况，多与临床医师沟通，准确进行编码。ObjectiveByreviewingandsummarizingtheproblemsexistinginthecodingofpersonalhistoryofmalignanttumorsinacancerhospital,andanalyzingthecausesofcodingerrors,toprovidereferenceforcoderstobettermasterthecodingmethodofpersonalhistoryofmalignanttumors.MethodsThemedicalrecordswithdiagnosticcodeZ85inacancerhospitalfromJanuary1,2020toDecember31,2021wereretrieved,andverifiedonebyoneaccordingtotheprinciplesofICD-10,andtheerrorsofcodingZ85werecounted.ResultsAtotalof1632medicalrecordshadZ85coding,ofwhich160caseswereincorrectlyused,withanerrorrateof9.80%.Amongthe160incorrectmedicalrecords,66caseswerewronginZ85codingsubmesh,accountingfor41.25%ofthetotalnumberofincorrectmedicalrecords.Therewere94casesofincorrectuseofZ85,accountingfor58.75%ofthetotalnumberofincorrectmedicalrecords.Thecausesofcodingerrorsincludedwrongclassificationoftumorlocationinthehistoryofmalignanttumors(26.25%),coderabuseofresidualcategoryzZ85.9(15.00%),tumorinthecurrentstate,observationperiod(38.75%),andnon-standardfillinginbyclinicians(20.00%).ConclusionTheclassif...
