Analysis of Disease Coding Defects in 1131 Cases of Breast Malignant Tumors
Objectives This study aims to check the disease coding of breast cancer in a certain hospital,analyze the causes of coding defects,and explore methods to improve the quality of breast cancer disease coding.Methods A total of 1,131 medical records of inpatient medical records of patients discharged from a certain hospital from January 1,2022 to December 31,2023,with the main diagnosis described as breast cancer on the front page,were retrieved.The main diagnosis codes of medical records were checked,and statistical analysis of error types and causes was performed.Results In 1131 cases of breast cancer,129 cases had coding defects,with a coding accuracy of 88.59％.The main types of errors were incorrect use of the fourth-character subdivisions of C50,incorrect use of C50,and incorrect use of Z51,etc.The causes of errors were over reliance on the coding database,insufficient mastery of coding rules,failure to read medical records carefully,lack of clinical knowledge,non-standard writing by clinicians,diagnostic errors by clinicians,and lack of pathological knowledge.Conclusions The disease coding of breast cancer should pay attention to both the location and morphology.The quality of breast cancer coding can be improved by improving the professional level of coders,optimizing working methods,establishing effective communication channels with clinical physicians,strengthening mutual training between coders and physicians,and improving coding quality control.
万方数据
维普
