【摘要】 目的 通过分析某三甲医院肝恶性肿瘤消融术主要诊断的疾病编码质量，发现存在的问题并提出改进对策，以提高编码准确率。方法 收集某院2024年1月1日—2024年12月31日肝恶性肿瘤接受消融治疗的患者261例，按照ICD-10肿瘤编码原则逐一核查主要诊断编码的准确性，统计错误编码的数量和类型，分析错误编码原因。结果 103份存在主要诊断编码错误，错误率为39.46%。肝恶性肿瘤首次消融治疗65例，错编8例（占7.77%）；残余病灶消融治疗35例，错编17例（占16.5%）；肝转移病灶消融治疗86例，错编25例（占24.27%）；再次出现新发病灶消融治疗75例，错编53例（51.46%）。结论 肝恶性肿瘤消融术主要诊断编码应结合病灶性质和治疗阶段进行精确编码，加强编码员培训、规范病案书写并构建质控体系，以提升病案数据质量。更多还原

【Abstract】 Objectives This study aims to analyze the quality of principal diagnosis coding in malignant liver tumor ablation cases in a tertiary hospital, identify existing problems, and propose improvement strategies to enhance coding accuracy. Methods Data on 261 patients with liver malignant tumors who underwent ablation therapy at a certain hospital from January 1, 2024 to December 31, 2024 were collected. The accuracy of the primary diagnosis codes was checked one by one according to the ICD-10 tumor coding principles, the number and types of incorrect codes were counted, and the reasons for the incorrect codes were analyzed. Results Among the 261 inpatient records included in the study, 103 cases contained incorrect principal diagnosis codes, yielding an error rate of 39.46%. Of the 65 patients who underwent initial ablation therapy for malignant liver tumors, 8 were incorrectly classified(7.77%); of the 35 patients who underwent ablation therapy for residual lesions, 17 were incorrectly classified(16.5%); of the 86 patients who underwent ablation therapy for liver metastases, 25 were incorrectly classified(24.27%); and of the 75 patients who underwent ablation therapy for newly developed lesions, 53 were incorrectly classified(51.46%). Conclusions Accurate coding of the principal diagnosis for malignant liver tumor ablation should consider both the nature of the lesion(primary, residual, metastatic, or newly developed) and the treatment stage. It is recommended to strengthen coder training, standardize clinical documentation practices, and establish a robust quality control system to improve the overall quality of medical record data.更多还原