病历书写质量对疾病与手术分类的影响

The Influence of Medical Record Writing Quality on Classification of Diseases and Surgery

目的探讨病历书写质量对疾病与手术分类影响的问题。方法分析病历书写质量对疾病与手术分类的影响。结果病历书写质量对疾病与手术分类的准确性影响较大。结论编码员应经常与临床医师沟通,相互学习。编码时必须详细、准确、全面的阅读病历,才能确保编码的准确性。

Objective To discuss the influence of medical record writing quality on classification of diseases and surgery.Methods Analyse the influence of medical record writing quality on classification of diseases and surgery combined with the practice experience.Results ICD is a highly technical work.There are many differences between disease diagnosis and disease coding.Medical record writing quality has a great impact on the accuracy of classification of diseases and surgery.Conclusion The coders should always be communicated with clinicians,learning from each other,and read the medical records in detail to ensure the accuracy of the code.