【摘要】 目的分析皮肤病损切除病案存在的易错的诊断和手术编码。方法检索2016年至2018年手术编码为86.3和86.4的病案716份,按主要诊断、手术操作和病理诊断名称分别进行分类统计。结果皮肤病损以良性肿瘤、囊肿和恶性肿瘤为最多,三者占比合计为94.2%。良性肿瘤以脂肪瘤为最多,囊肿以皮肤和皮下组织毛囊囊肿为主,恶性肿瘤中较多的为基底细胞癌和鳞状细胞癌。皮肤良性肿瘤经常错误地编码为某部位的良性肿瘤,出院时仍以肿物进行诊断编码也是常见错误,不熟悉皮肤病损的病理诊断编码也是导致诊断编码错误的原因之一。手术以皮下组织病损切除术、皮肤病损切除术为最多,没有严格以皮肤病损的具体解剖部位进行手术编码是这些病例手术编码错误的主要原因。结论加强对编码员、临床医师关于皮肤病损病例的疾病诊断和手术编码知识的培训,熟悉皮肤病损病例的编码注意事项,同时编码员与临床医师之间要有有效和便捷的沟通渠道,如此,才能提高这些病例编码的质量。更多还原

【Abstract】 Objective To analyze the error-prone diagnosis and surgical coding of skin lesion excision.Methods Retrieving the cases in the past three years with 86.3 and 86.4 suborder of surgery,716 cases were classified and counted according to the names of main diagnosis,operation and pathological diagnosis.Results Benign tumors,cysts and malignant tumors were the most common skin lesions,accounting for 94.2% of the total.Lipoma is the most benign tumor,skin and subcutaneous hair follicle cyst is the main cyst,and basal cell carcinoma and squamous cell carcinoma are the most malignant tumors.Benign tumors of skin are often mistakenly encoded as benign tumors of a certain site.It is also a common mistake to still use tumors for diagnosis when leaving hospital.The reason for the wrong diagnosis code is that the patient is not familiar with the pathological diagnosis code of skin lesions.The main reason for the error of surgical coding in these cases is that the surgical coding is not strictly based on the specific anatomical parts of the skin lesions.Conclusion Strengthen the training of coders and clinicians on the disease diagnosis and operation coding knowledge of skin lesions,be familiar with the coding precautions of skin lesions,and have effective and convenient communication channels between coders and clinicians,so as to improve the quality of these cases coding.更多还原