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正确书写疾病诊断对ICD编码的影响
引用本文:周立宁.正确书写疾病诊断对ICD编码的影响[J].中国病案,2011,12(12):18-19.
作者姓名:周立宁
作者单位:河池市第一人民医院病案室,广西,546300
摘    要:目的规范疾病诊断书写,提高编码的准确性,充分发挥病案信息资源作用。方法根据疾病诊断正确书写方法及ICD-10编码要求,对临床疾病诊断书写存在的问题及其对编码准确性的影响进行分析。结果准确的编码首先来源于疾病诊断的正确书写,其次是编码员医学知识水平、掌握编码原则和方法的程度。结论加强临床医师ICD-10分类知识及诊断书写培训,提高编码人员医学知识、专业知识水平及加强责任心,才能确保编码准确。

关 键 词:疾病诊断  国际疾病分类  编码

The Influence of Correct Disease Diagnosis Writing to ICD Coding
Zhou Lining.The Influence of Correct Disease Diagnosis Writing to ICD Coding[J].Chinese Medical Record,2011,12(12):18-19.
Authors:Zhou Lining
Institution:Zhou Lining,Medical Record Office,the First People's Hospital of Hechi,Yizhou 546300,Guangxi Autonomous Region,China
Abstract:Objective The aims of our study were to standardize the writing of disease diagnosis writing,to improve the accuracy of coding and to fully play the role of information resource of medical record.Methods According to the requirements of the correct writing methods of disease diagnosis and ICD-10 coding,this article analyzed the existing problems in clinical disease diagnosis writing and its effect on accuracy of coding.Results The correct coding firstly depends on the correct writing of disease diagnosis,se...
Keywords:Disease diagnosis  International classification of diseases  Coding  
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