病案首页主要诊断选择的个案分析

Case Analysis of Primary Diagnosis Choice of the Front Sheet of Medical Record

列举编码工作中的实际案例,以讨论的形式分析临床医师在病案首页中填写主要诊断对疾病分类工作的影响,同时作为编码人员通过提高专业水平和不断学习临床知识,审核和监督病案首页中临床医师主要诊断的填写,最大限度减少疾病诊断填写错误,保证病案信息资料的准确性。总结出科学、准确的疾病编码有赖于临床医师和病案编码人员的共同努力及规范的管理。

List practical eases in classification work. Discuss the influence of clinical physician writing primary diagnosis on the front sheet of medical record to disease classification work. Coding personnel audit and supervision main diagnostic fill in of clinical physicians, minimize disease diagnosis fill in errors, ensure the accuracy of the medical record information through improve their professional level and keep learning clinical knowledge. The scientific and accurate disease coding depends on the joint efforts of the clinical physicians and medical record coding staff and standardized management.