病案首页中疾病与手术编码存在的问题与分析

目的诊断相关分组-预付费制度的实施,疾病分类编码工作对医院的经营管理有着十分重要的作用,通过对病案首页编码内容进行回顾性检查,找出影响编码正确性的问题,提高疾病和手术操作编码准确率,提高报表质量。方法抽检部分三甲医院和二级医院上报病案数据进行分析。结果检查的695份病案中,主要诊断的选择和手术编码存在的问题258例,占总检查数的37%。结论编码员不仅要加强相关业务知识的学习,同时要多与临床医师沟通,提高医师书写诊断正确率和编码正确率。

Problems of Coding Existing in the Home Pages of Medical Records and Relevant Analysis

Objective The application of the regime of diagnosis related group-payment in advance has play an important role in the coding work. Through conducting a retrospectively examination on the coding contents in home pages, this article found out the problems that influenced the accuracy of coding, and improved the coding accuracy of diseases, operation and the quality of report forms. Result In all of the 695 cases of medical records in this examination, 258 cases were found out problems in major diagnosis or operation coding, which took 37%. Conclusion Our coding staff should not only strengthen the study of related professional knowl- edge, but also communicate with clinical doctors moreoften, thus to improve the accuracy of diagnosis written by doctors as well as the accuracy of coding.