疾病编码的影响因素及改进对策

分析影响疾病编码正确性的因素,临床医师的因素有主要诊断选择错误、病案首页填写不准确等,编码人员的因素有临床知识欠缺、过度依赖电脑编码库等。改进编码准确性的对策主要有编码人员应提高专业水平和学习临床基础知识,临床医师应掌握疾病编码的分类原则。准确的疾病编码有赖于临床医师、病案编码人员的共同努力及规范的管理,准确的疾病编码对病案的利用具有极大的影响。

Influencing Factors and Improving Countermeasures of Disease Coding

Factors affecting the accuracy of disease coding include the reasons of clinicians and the coders.The reasons of clinicians are the wrong choice of main diagnosis and unaccurately filling of the medical record,and the reasons of the coders is the lack of clinical knowledge and over-reliance on computer code library.The main countermeasures to improve coding accuracy are as follows.Coders should raise the professional standards and learning basic clinical knowledge,and clinicians should master the principles of classification of disease coding.The accuracy of disease coding depends on the joint efforts of clinicians and coders,and the standardized management.The accuracy of disease coding has a great impact on the use of medical record.