Objective To explore the reasons and improvement measures for incorrect and missed filling code of clinicians in the tumor diagnosis.

Methods Based on the combination of "Medical Record Home Page Retrieval System" and "Pathology Report System", we screened out the cases with ICD-10 code C00-D48 on the home page of hospital medical records from January 2019 to July 2019, checked the results of pathology report correspondingly, analyzed the causes of the problems according to the cases with errors and omissions in tumor diagnosis codes found correspondingly, and then screened by the same method after quality improvement measures were formulated and implemented (from January 2020 to July 2020).

Results From January to July, 2019, a total of 12 382 cases were collected, of which 2 712 (21.92%) cases had errors and omissions in pathological diagnosis codes. From January to July, 2020, among the 11 872 cases, there were 1 272 (10.70%) cases with errors and omissions. The difference between the two groups was statistically significant (P < 0.05). The error and omission rate of tumor diagnosis code was lower than that before improvement, and the improvement rate was 11%. In 2019, there were 2 712 errors and omissions caused by errors in clinical coding principles, uncertain pathological results, and delayed pathological reporting time, accounting for 12%, 6%, and 4% of the total cases, respectively. In 2020, the cases caused by the error of clinical coding principle, uncertain pathological results, and delayed pathological reporting time all showed obvious improvement (P < 0.05). Among them, the error rate of clinical coding principle decreased by 7%, and the error rates caused by uncertain pathological results and delayed pathological reporting time decreased by 3% and 2% respectively.

Conclusions Through a series of quality improvement measures, the quality of tumor diagnosis coding can be obviously improved.