脑膜瘤形态学编码分析

Morphological Coding Analysis of Meningiomas

目的脑膜瘤病理类型分级分型较多,造成脑膜瘤编码困难,参照脑膜瘤分类标准、ICD-O-3原则,分析脑膜瘤编码特点,以提高编码的准确率。方法利用医院病案查询系统检索出某院2014年1月至2016年6月疾病诊断为脑膜瘤病案103例,以ICD-O-3分类规则,分析某院近2年多"脑膜瘤"的形态学编码情况,对存在的问题进行汇总分析。结果编码错误共17例,错误率16.50%,其中因编码员对脑膜瘤病理分型不熟悉,错误分类于M8000/0良性肿瘤NOS或M9530/0脑(脊)膜瘤NOS有16例,占15.53%;错编有1例,占0.97%。结论编码人员对脑膜瘤分级分型不熟悉,缺乏质控环节,编码库滞后于临床发展等原因均易造成编码错误,所以编码人员必须仔细阅读病历、病理报告,主动与临床、病理医师沟通,更新相关知识结构,不断提高脑膜瘤编码的准确性。

Objectives There were many kinds of pathological types of meningiomas which caused coding difficulties. With reference to the pathological typing of meningiomas and ICD-O-3 classification principle, to analyze the characteristics of the meningioma coding and improve the accuracy of the coding of the meningiomas.Methods Using hospital medical record data query system to retrieve 103 cases of meningiomas from January 2014 to June 2016.To analyze morphological coding of meningiomas with the regulation of ICD-O-3 classification in recent two years,and make summary and analysis on the existing problems.Results There were 17 cases of error coding totally,accounted for 16.50%.Because of the unfamiliar of pathological typing of meningiomas the coders classified morphological coding of meningiomas to M8000/0 NOS or M9530/0 NOS,this type of the error coding were 16 cases,accounted for 15.53%,wrong coding was 1 case,accounted for 0.97%.Conclusions The coders would be easy to make mistakes in coding because of being unfamiliar with pathological typing of meningiomas,lack of quality control system and the development of coding library fall behind clinical development.So the coders must carefully read the medical records and pathological reports,actively communicate with the clinician and pathologist,update the related knowledge structure,and keep improving the accuracy of the coding.