摘要
目的了解单病种病历病案首页填写存在问题。方法依据医院实际单病种结算数据为基础,与病案室编码员后期ICD-10编码进行比对、分析。结果 1 874份医保单病种结算病历中存在编码错误242份,占13%。结论应加强临床医师对疾病分类细则的学习和掌握,提高编码员的责任心,共同提高主要诊断编码的准确性,减少单病种结算途径错误。
Objective To observe the problems in filling in the front page of single disease medical records. Meth- ods According to the settlement data of the actual single disease in hospitals, we made comparison and analysis on ICD - 10 encoded by the coders of the medical record room in a later period. Results Among the 1 874 medical records of single dis- ease for medicare insurance, 242 records had problems in encoding en＇ors, accounting for 13%. Conclusion Something should be done to strengthen the ability of the clinical physicians to learn and master the classification rules, improve the sense of responsibility of coders, jointly increase the accuracy of the main diagnostic coding, and reduce settlement errors of single disease.
出处
《现代医院》
2016年第5期772-774,共3页
Modern Hospitals
关键词
单病种
主要诊断
填写缺陷
Single disease
Primary diagnosis
Filling defect
