病案首页主要诊断选择缺陷分析

Analysis of Major Diagnosis Selection Defect of Medical Record Home Pages

目的通过对某医院2017年出院患者的病案首页主要诊断存在的缺陷情况进行分析,并提出对策,为医院的医疗质量管理和医疗信息提供依据。方法根据国际疾病分类原则,对42 124份出院病案首页主要诊断进行审核。结果缺陷的内容主要是疾病诊断名称书写不规范、主要诊断选择错误。阐述了选择主要诊断的方法和技巧。结论提出加强对医师进行国际疾病分类知识的培训和指导,有助于临床医师正确书写主要诊断,提高ICD编码的准确性,确保医疗信息的统计质量。

Objective To analyze the major diagnosis selection defect of Medical record home pages in a certain hospital in2017 and put forwards the strategies thus providing basis for the medical quality management and medical information in the hospital. Methods 42 124 pieces of discharged medical record home pages were reviewed according to the classification principles of international diseases. Results The major defect contents were the non-standardized disease diagnosis title writing and incorrect selection of major diagnosis, and the paper elaborates the major diagnosis method and skill. Conclusion We should enhance the training and guidance of international disease classification knowledge of physicians thus helping the clinical physicians accurately write the major diagnosis, improving the accuracy of ICD code and ensuring the statistical quality of medical information.