摘要
目的通过错误编码统计,分析探讨Z85类目的错误类型及正确使用规则。方法利用某医院首页信息管理系统检索2006年-2015年10年间Z85编码的使用情况。结果检索出采用Z85编码的出院病案共8606份,其中以原发恶性肿瘤(C00-C76,C80)并发Z85的出院病案1838份,编码错误率为21.4%;以继发恶性肿瘤(C77-C79)并发Z85的出院病案1010份,编码错误率为11.7%。结论 Z85只适用于当存在某种影响人的健康状况、但肿瘤本身并不是一个现有疾病的情况。当肿瘤患者正在接受肿瘤的治疗、随诊或康复时,Z85编码不能使用。正确应用Z85类目在恶性肿瘤信息检索中具有重要作用,在实际应用中可以用作并发条件检索出患"双原发恶性肿瘤"的患者数,为临床科研提供准确的数据。
Objective To discuss the proper use of category Z85 through the miscoding analysis of Z85. Method All codes with category Z85 were searched in one hospital＇ s management information system of front sheet of medical records from 2006 to 2015 and the error rates were calculated. Results 8606 records using Z85 codes are searched out, among which 1838 records are primary malignant neoplasm with Z85, accounting for 21.4% of the total; 1010 records are secondary malignant neoplasm with Z85, accounting for 11.7% of the total. Conclusion Category Z85 plays a very important role in malignant neoplasm data searching. It could be used as concurrent condition to search for the patients with double primary malignant neoplasm. Category Z85 could be used when some circumstance or problem is present which influence the person＇ s health status but is not in itself a current illness. When a person with malignant neoplasm is receiving follow-up medical care, convalescene or follow-up examination after treatment of malignant neoplasm, Z85 could not be used. Proper use of it could serve as an additional path to provide accurate data for clinical research.
出处
《中国病案》
2017年第2期29-30,共2页
Chinese Medical Record
