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中文摘要: 目的：系统分析某三甲中医院2024年直肠癌根治术编码质量现状，归纳错误类型并提出改进策略，为提升病案数据准确性提供依据。方法：采用回顾性研究方法，通过医院病案统计管理系统调取2024年1-12月全部直肠癌根治术病例224例。由复核小组采用双人独立审核与交叉验证的方式，对手术编码准确性进行核查，并分类统计错误类型。结果：224份直肠癌手术病案分析显示，共有99份病案存在编码错误，总体错误率为44.2%。其中，主要手术编码错误65份，主要由于临床医师使用“根治术”等非标准术语所致，占比86.15%；其他手术编码错误52份，主要由于造口术性质未明确所致，占比84.62%。此外，有18份病案同时存在上述两类错误。结论：直肠癌根治术编码质量受多重因素影响，包括手术术式的分类标准、解剖学定位、手术切除范围等，需建立标准化编码流程和培训体系，加强多学科协作联动，以提高编码质量。
中文关键词: 直肠癌根治术 ICD-9-CM-3 编码员
Abstract:Objective：To systematically analyze the current status of coding quality for radical rectal cancer surgery in a certain grade A tertiary Chinese medicine hospital in 2024，summarize the types of errors，and propose improvement strategies to provide a basis for enhancing the accuracy of medical record data. Methods：A retrospective study was conducted. All 224 cases of radical rectal cancer surgery from January to December 2024 were retrieved from the hospital’s medical record statistics management system. A review team independently reviewed and cross-validated the accuracy of surgical coding in a double-blind manner，and classified and statistically analyzed the types of errors. Results：Analysis of 224 rectal cancer surgery medical records showed that 99 records had coding errors，with an overall error rate of 44.2%. Among them，65 records had errors in the main surgical coding，mainly due to the use of non-standard terms such as “radical surgery” by clinicians，accounting for 86.15%；52 records had errors in other surgical coding，mainly due to the unclear nature of stoma surgery，accounting for 84.62%. Additionally，18 records had both types of errors. Conclusion：The quality of coding for radical rectal cancer surgery is influenced by multiple factors，including the classification standards of surgical procedures，anatomical location，and the extent of surgical resection. It is necessary to establish a standardized coding process and training system，and strengthen multi-disciplinary collaboration and interaction to improve coding quality.
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基金项目:国家卫生健康委医院管理研究所医疗质量（循证）管理研究项目（YLZLXZ24G052） 国家卫生健康委医院管理研究所医疗质量（循证）管理研究项目（YLZLXZ24G052）
引用文本：
王竹君,汪 静,王 丹,吴植茆*.直肠癌根治术ICD-9-CM-3编码质量分析△[J].江苏卫生事业管理,2026,37(6):835-838.
WANG Zhujun,WANG Jing,WANG Dan,WU Zhimao*.Quality Assessment of ICD-9-CM-3 Coding for Radical Rectal Cancer Resection△[J].Jiangsu Health System Management,2026,37(6):835-838.
王竹君,汪 静,王 丹,吴植茆*.直肠癌根治术ICD-9-CM-3编码质量分析△[J].江苏卫生事业管理,2026,37(6):835-838.
WANG Zhujun,WANG Jing,WANG Dan,WU Zhimao*.Quality Assessment of ICD-9-CM-3 Coding for Radical Rectal Cancer Resection△[J].Jiangsu Health System Management,2026,37(6):835-838.
