通信作者:罗坚，13924009909@139．com肿瘤化疗后骨髓抑制编码分析邓梅君李燕菁刘丹丹曾成力罗坚广东省妇幼保健院广东广州511400【摘要】目的通过分析某三甲医院病案首页肿瘤化疗后骨髓抑制编码的常见错误及原因，提高肿瘤化疗后骨髓抑制编码准确性。方法利用病案统计管理系统检索某院2019年1月1日—12月31日期间出院诊断编码中包含Z51.1或D70或D69.5或D61.1的病案，筛选出肿瘤化疗后存在骨髓抑制的病案，并分析骨髓抑制编码错误的类型及原因。结果共611份肿瘤化疗后存在骨髓抑制的病案，其中515份编码错误，错误率达到84.3%。在错误原因分析中，错误率最高的是医师漏填写骨髓抑制相关的诊断，其次为编码员错编和漏编。结论肿瘤化疗后骨髓抑制编码错误率高，需要临床医师规范书写首页诊断、编码员加强临床知识和编码规则的学习，以提高编码准确率。【关键词】骨髓抑制;肿瘤;化疗;ICD-10中图分类号:Ｒ197．323．1文献标志码:Adoi:10．3969/j．issn．1671－332X．2023．02．017MyelosuppressioncodingaftertumorchemotherapyDENGMeijun，LIYanjing，LIUDandan，ZENGChengli，LUOJianGuangdongWomen’sandChildren’sHospital，Guangzhou511400，China【Abstract】ObjectiveToimprovetheaccuracyofchemo-inducedmyelosuppressioncodingbyanalyzingthecommoner-rorsandcausesofmyelosuppressioncodingonthehomepageofmedicalrecordsinatertiaryhospital．MethodsAmedicalcasestatisticalmanagementsystemwasusedtoretrievecasescontainingZ51．1orD70orD69．5orD61．1inthedischargediagnosiscodeofahospitalfromJanuary1sttoDecember31st，2019，toscreenoutmedicalrecordswithmyelosuppressionaftertumorchemotherapyandanalyzethetypesandcausesofmyelosuppressioncodingerrors．ＲesultsTherewere611casesofmyelosup-pressionafterchemotherapy，ofwhich515werecodedincorrectly，withanerrorrateof84.3%．Byanalysingtheerrors，itwasfoundthatthemostcauseswerethephysician’somissiontofillinthediagnosisrelatedtomyelosuppression，followedbytheco-der’smiscodingandomissions．ConclusionThecodingerrorrateofmyelosuppressionaftertumorchemotherapyishigh．There-fore，cliniciansmuststandardizethewritingofhomepagediagnoses，andcodersshouldimprovetheirclinicalknowledgeandcod-ingrules，soastoimprovecodingaccuracy．【Keywords...
