脑梗死病例编码的多学科讨论实践

Practice of multidisciplinary discussion on case coding of cerebral infarction

建立有效的病案首页填写沟通机制是保证疾病诊断相关分组良好运行的重要措施。作者以脑梗死为例,围绕其编码轴心,开展基于病种的多学科协作模式试点工作。多学科协助模式可以为多个学科之间提供良好的交流和学习平台,打破学科间的壁垒,既提高临床医生首页和病历书写的质量,又提高编码员编码的质量和效率。

It is an important measure to establish an effective communication mechanism for filling in the front page of medical records to ensure the good operation of diagnosis-related groups.Taking cerebral infarction as an example,the authors carried out the pilot work of multidisciplinary cooperation mode based on disease types around its coding axis.The multi-disciplinary assistance model could provide a good platform for communication and learning among multiple disciplines,break the barriers between disciplines,improve the quality of the front page and medical record writing of clinicians,and improve the quality and efficiency of coders′coding.