摘要
目的分析医师填写病案首页疾病诊断和编码的情况,探讨医师进行疾病编码方法的可行性。方法回顾性调查和分析我院2012年1月至2013年6月病案首页医师填写疾病名称和疾病编码的状况。结果 22035份住院病案首页中疾病名称填写不规范、主要诊断选择和疾病编码错误比例为7.8%。结论目前情况下暂不适宜临床医师承担疾病编码工作;加强临床医师了解ICD-10知识,促进病案编码员掌握ICD-10编码原则,确保疾病编码的准确性。
Objective To analyze the fill in of disease diagnosis and coding by physician, and discuss the feasibility of physicians for disease coding. Methods Retrospectively investigating and analyzing disease name and codes in our hospital between January 2012 and June 2012. Results In 22035 front sheet of medical record, the error ratio of the non-standard diseases fill in and Selection of diagnosis and disease coding is 7.8%. Conclusion Disease coding work temporarily not suitable for clinical physicians in current situation. We should strengthen the knowledge of ICD-10 for chnicians, strengthen the principle of ICD-10 for coders, ensure the accuracy of disease coding.
出处
《中国病案》
2014年第1期39-41,共3页
Chinese Medical Record
关键词
病案首页
医师
编码
病案管理
The front sheet of medical record
doctor
Coding
Medical record management
