| 2475份病案首页中主要诊断选择错误分析及对策 |
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| 引用本文： | 赵小佳,黄碧波,李建军.2475份病案首页中主要诊断选择错误分析及对策[J].中国病案,2013(9):14-15. |
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| 作者姓名： | 赵小佳 黄碧波 李建军 |
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| 作者单位： | 首都医科大学附属复兴医院,北京市100038 |
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| 摘 要： | 目的 对病案首页中主要诊断选择中存在的问题进行分析,探寻提高其正确率的有效措施.方法 收集出院病案首页2475份,按照ICD-10编码原则,分析主要诊断的选择与书写情况,对出现的错误进行汇总分析.结果 存在主要诊断选择错误439份,以恶性肿瘤疾病、妇科系统疾病、心血管疾病、血液恶性疾病位居前4位,4者共占73.7%.结论 加强临床医师对国际疾病分类相关知识的了解,提高编码员对临床诊断的分类能力,加大质控医师对主要诊断的质控,才能提高主要诊断选择正确率,确保信息统计的可靠性.
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| 关 键 词： | 病案首页 主要诊断 ICD-10编码 |
Analysis and Countermeasures of Principal Diagnosis Mischoose of 2475 Cases of The Front Sheet of Medical Records |
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| Zhao Xiaojia,Huang Bibo,Li Jianjun.Analysis and Countermeasures of Principal Diagnosis Mischoose of 2475 Cases of The Front Sheet of Medical Records[J].Chinese Medical Record,2013(9):14-15. |
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| Authors: | Zhao Xiaojia Huang Bibo Li Jianjun |
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| Institution: | ( Beijing Fuxing Hospital Affiliated to Capital Medical University, Beljing 100038, China) |
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| Abstract: | Objective To analyze the existing problems of principal diagnosis selection of the front sheet of medical records, and explore effective measures to improve its accuracy. Methods Collecting 2475 cases of the front sheet of medical records, and analyzing the choice and writing of main diagnosis. Results A total of 439 cases of the front sheet of medical records have principal diagnosis mischoose. The top four diseases are malignant tumor, gynecological disease, cardiovascular disease, hematological malignant diseases, accounting for 73.7 %. Conclusion We should strengthen the clinicians understanding of ICD relevant knowledge, improve the classification ability of coders, increase quality control for the main diagnosis of quality physicians to ensure the reliability of the information statistics. |
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| Keywords: | The front sheet of medical record Principal diagnosis ICD-10 coding |
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