Objective By reviewing and summarizing the problems existing in the coding of personal history of malignant tumors in a cancer hospital,and analyzing the causes of coding errors,to provide reference for coders to better master the coding method of personal history of malignant tumors.Methods The medical records with diagnostic code Z85 in a cancer hospital from January 1,2020 to December 31,2021 were retrieved,and verified one by one according to the principles of ICD-10,and the errors of coding Z85 were counted.Results A total of 1632 medical records had Z85 coding,of which 160 cases were incorrectly used,with an error rate of 9.80％.Among the 160 incorrect medical records,66 cases were wrong in Z85 coding submesh,accounting for 41.25％of the total number of incorrect medical records.There were 94 cases of incorrect use of Z85,accounting for 58.75％of the total number of incorrect medical records.The causes of coding errors included wrong classification of tumor location in the history of malignant tumors(26.25％),coder abuse of residual category Z85.9(15.00％),tumor in the current state,observation period(38.75％),and non-standard filling in by clinicians(20.00％).Conclusion The classification of malignant tumor history was complex and its use was complex.Coders should avoid using residual categories,master the use of Z85,communicate more with clinicians,and code accurately.
关键词
恶性肿瘤/个人史/国际疾病分类
Key words
Malignant tumors/Personal history/International classification of diseases(ICD)
维普
万方数据