【摘要】 目的甲状腺乳头状癌的变异亚型较多,造成甲状腺乳头状癌编码困难,容易错编,故本文参照甲状腺肿瘤的组织学分类标准、ICD-O-3原则,分析甲状腺乳头状癌编码特点,以提高编码的准确率。方法利用医院病案信息查询系统检索出某院2016年1月至2018年12月疾病诊断为甲状腺乳头状癌病案417例,以ICD-O-3分类规则,分析某院近3年"甲状腺乳头状癌"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159例,错误率38.13%。其中错误分类于M8000/3恶性肿瘤NOS有2例,占0.48%;错误分类于M8050/3乳头状癌有149例,占35.73%;因疾病分类人员对甲状腺乳头状癌病理变异亚型不熟悉,病理诊断已给出具体亚型,仍错误分类于M8260/3乳头状腺癌有8例,占1.92%;漏编形态学1例,占0.24%。结论疾病分类人员对甲状腺乳头状癌的病理特点及变异亚型不熟悉,缺乏首页编码质控环节,编码库相对滞后于临床发展等原因均易造成编码错误,所以疾病分类人员必须仔细阅读病历、病理报告,主动与临床医师、病理医师沟通,更新相关知识结构,不断提高甲状腺乳头状癌编码的准确率。更多还原

【Abstract】 Objective There are more variant subtypes of thyroid papillary carcinoma, which cause difficult coding of thyroid papillary carcinoma and are prone to miscoding. According to the histological classification criteria of thyroid tumors and the ICD-O-3 principle, the coding characteristics of thyroid papillary carcinoma are analyzed to improve the coding accuracy rate.Methods The hospital medical record information inquiry system was used to retrieve 417 cases of thyroid papillary cancer diagnosed from January 2016 to December 2018 in a hospital. The ICD-O-3 classification rule was used to analyze the morphological coding situation of thyroid papillary carcinoma in a hospital for nearly 3 years. The existing problems were summarized and analyzed.Results There were 159 coding errors and the error rate was 38.13%. Among them, 2 cases of NOS were misclassified in M8000/3 malignant tumor, accounting for 0.48%; 149 cases were misclassified in M8050/3 papillary carcinoma, accounting for 35.73%; the disease classifier was not familiar with the pathological variant subtype of papillary thyroid carcinoma. Pathological diagnosis had given specific subtypes, but was misclassified in M8260/3 papillary adenocarcinoma in 8 cases, accounting for 1.92%; missing morphological morphology was 1 case, accounting for 0.24%.Conclusion Disease classifiers are unfamiliar with the pathological features and variant subtypes of thyroid papillary carcinoma, lack the homepage quality control link, and the coding library is relatively lagging behind clinical development. These reasons are likely to cause coding errors, so disease classification personnel must carefully read the medical records and pathology reports, actively communicate with clinicians and patho logists, update relevant knowledge structures, and continuously improve the accuracy of thyroid papillary cancer coding.更多还原