分析病案首页中疾病诊断及编码存在的问题

Analysis of the Problems in the Diagnosis and Coding of the Disease in the First Page of Medical Records

目的 通过对病案首页编码内容的回顾性分析,找出影响编码正确性的问题,并进行有效的处理,以提高疾病诊断和编码的准确率。方法 采用回顾性分析的方式,对我院2013年3月~2015年3月的数据进行分析和总结。结果 经过资料整合,在选取的500例病案资料中,主要诊断的选择和编码存在的问题共计155例,占总检查例数的31.00%。结论 编码员不仅要通过一切可行的方法增强自身的业务能力以外,在临床工作中还要尽可能多的与临床医师进行沟通和交流,以有效提高医师书写诊断正确率和编码正确率。

Objective To analyze the contents of the first page of medical records, to find out the problems that affect the correctness of the coding, and to improve the accuracy of diagnosis and coding. Methods Retrospective analysis was used to analyze and summarize the data from March 2013 to March 2015 in our hospital. Results After data integration, in the selection of 500 cases of medical records, the main diagnosis of the selection and coding problems in a total of 155 cases, accounting for 31.00% of the total number of cases. Cnnelusinn Encoding staff not only to enhance their business capacity through all feasible methods, in clinical work, but also as much as possible to communicate with the clinician, to improve physician writing diagnosis accuracy and the correct rate of encoding.