摘要
目的 分析肾细胞癌病理亚型形态学编码,提高形态学编码准确率.方法 通过医院病案信息系统检索某三甲综合医院2022年6月1日-2023年6月30日出院的主要诊断ICD-10编码为C64,且病理诊断为透明细胞肾细胞癌、乳头状肾细胞癌、肾细胞癌伴肉瘤样变、嫌色肾细胞癌、髓质样肾细胞癌的病案共计153份.结果 在153份病案中,编码员形态学编码错误的有86份,错误率为56.2％.错误占比分别为透明细胞肾细胞癌66.28％、乳头状肾细胞癌17.44％、嫌色肾细胞癌8.14％、肾细胞癌伴肉瘤样变5.82％、髓质样肾细胞癌2.32％.结论 肾细胞癌病理亚型较多,形态学编码较为复杂,编码人员应主动学习最新的WHO肿瘤分类,掌握ICD肿瘤编码规则,提高临床知识储备,与临床医师和病理科的医师建立有效的沟通机制,完善编码质控环节等方法提高编码准确率.
Abstract
Objectives This study aims to analyze the morphological coding of pathological subtypes of renal cell carcinoma and improve the accuracy of morphological coding.Methods A total of 153 medical records were retrieved from a tertiary comprehensive hospital from June 1,2022 to June 30,2023,using the hospital medical record information system.The main diagnostic ICD-10 code was C64,and the pathological diagnosis was clear cell renal cell carcinoma,papillary renal cell carcinoma,renal cell carcinoma with sarcomatoid transformation,chromophobe renal cell carcinoma,and medullary renal cell carcinoma.Results Among 153 medical records,86 of them had morphological coding errors by coders,with an error rate of 56.2％.The pathological diagnoses with a high proportion of errors were clear cell renal cell carcinoma,papillary renal cell carcinoma,chromophobe renal cell carcinoma,renal cell carcinoma with sarcomatoid transformation,and medullary renal cell carcinoma,with error rates of 66.28％,17.44％,8.14％,5.82％,and 2.32％,respectively.Conclusions Renal cell carcinoma has multiple pathological subtypes and complex morphological coding.Encoders should actively learn the latest WHO tumor classification,master the ICD tumor coding rules,improve clinical knowledge reserves,establish effective communication mechanisms with clinical physicians and pathologists,and improve coding quality control methods to improve coding accuracy.
维普
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