病案书写质量对疾病编码的影响

The impact of medical record quality on disease coding

在医护工作开展中,病案书写是非常重要的技能,其为严格根据患者疾病表现、诊疗情况进行记录的档案,能够对患者诊疗经过、归转情况以及病情变化情况进行客观完整的记录,如果没有做好处理,则可能对编码的准确性产生影响.对此,即需要能够积极做好实际工作中存在问题情况的把握,在提升书写质量的基础上最大程度保障疾病编码质量.

During the course of medical care work,the writing of medical records is a very important skill.The medical records are files that produced strictly according to the patient’s disease performance as well as the diagnosis and treatment,which can objectively and completely record the patient’s diagnosis and treatment,regression status and changes in the condition of the patient.If not handled well,it may have an adverse impact on the accuracy of the coding.In this regard,it is necessary to be able to actively handle the problems in the actual work,and to maximize the quality of disease coding on the basis of improving the quality of writing.