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目的了解胃肠间质瘤的疾病编码现状,以提高编码准确率。方法于某院电子病案系统筛选2000年1月-2016年6月的胃肠间质瘤住院病例,收集临床诊断、病理及疾病编码信息。比较目前的编码结果和基于《中国胃肠间质瘤诊断治疗共识(2013年版)》标准的ICD-O编码结果,并分析编码错误的原因。结果 213例胃肠间质瘤中需修正疾病编码者达158例,占74.2%。其中,因编码库更新不及时的107例,占67.7%,因编码员编码标准不一致的40例,占25.3%,余者为未送检病理或病理报告信息不完整,占7.0%。结论胃肠间质瘤疾病编码准确率低,最主要原因是编码库更新不及时及编码标准不一致。通过积极查阅权威文献,与临床及病理医师讨论后确定统一标准,及时更新编码库,可提高编码准确率。
Objective To understand the status of gastrointestinal stromal tumor coding in order to improve the coding accuracy. Methods The hospitalized cases of gastrointestinal stromal tumors from January 2000 to June 2016 were screened in a hospital electronic medical record system to collect clinical diagnosis, pathology and disease coding information. ICD-O coding results based on the current coding results and based on the “consensus of diagnosis and treatment of gastrointestinal stromal tumors (2013 edition)” were compared and the reasons for coding errors were analyzed. Results In 213 cases of gastrointestinal stromal tumors, there were 158 cases requiring correction of disease codes, accounting for 74.2%. Among them, 107 cases (67.7%) did not update in a timely manner due to the update of coding library, 40 cases (25.3%) were inconsistent with coding standard of coder, and the remaining cases were incomplete or accounted for 7.0% of unreleased pathological or pathological reports. Conclusion The main reason for the low accuracy of gastrointestinal stromal tumor coding is that the update of the coding library is not timely and the coding standards are inconsistent. By actively consulting authoritative literature, discussing with clinicians and pathologists to determine uniform standards and updating coding libraries in time, the coding accuracy can be improved.