提高死亡病案主要诊断准确性的探讨

How to Improve the Accuracy of Choosing the Main Diagnosis of Death Records

通过对某院2013年1-9月315份住院死亡病历主要诊断书写的监控,了解医生选择主要诊断的准确性与患者病情有无关系,分析造成错误的原因,是临床医师对病案首页主要诊断的选择重视不够;医学院校从根本上忽视了对医师的教育培训;编码人员对病案首页主要诊断选择的原则掌握不够熟练。文章提出重视对医院每年新毕业的毕业生,新调来院的医师,实习医师,进修医师的上岗前培训;加强临床医师和编码人员的定期培训,及时了解疾病分类和主要诊断选择的最新动态;加强运行病历和终末病历的质控力度,督促临床医师正确、规范地书写病案首页中的每一个诊断。

Through monitoring the main diagnosis of 315 death records from 1-9 month in 2013,understanding the relationship be- tween the accuracy of the main diagnosis and the patient＇s condition ,analyzing the causes of the errors, to investigate the Effective measures to improve the accuracy of the choosing of the maindiagnosis. The main reason of the inaccurate of main diagnosis is no enough attention on choosing the main diagnosis ;ignoring the education and training of the doctors; unskilled coder in mastering the principles of choosing main diagnosis. Countermeasures pay attention to the training of the graduates, new doctors, interns and the refresher doctors. Strengthen the reg- ular training of the coders and the quality control, supervise and urge the correct and standard writing of diagnosis of doctors.