浅谈基于疾病发展链的重症疾病并发症编码模式

Discussion on coding model of severe disease complications based on the chain of disease development

DRGs和公立医院绩效考核工作在二级医院的开展,使疾病编码工作的重要性进一步的提升,疾病编码不仅要求正确,也要求完整,但由于临床思维和疾病编码的要求存在一定的差异,医生使用重症、重度等词对疾病针对疾病进行修饰,特别是疾病编码2.0对部分疾病进行了细化扩展,容易在编码时忽略了疾病分类的内涵造成重症疾病的信息丢失。运用疾病发展链的观念对疾病发展过程进行检视,能够更有效的提高重症、重度疾病的编码完整性。

DRGs and Performance appraisal of public hospitals unfold in secondary hospitals,further increasing the importance of disease coding.Disease Coding requires not only correctness but also completeness.However,there are some differences between clinical thinking and disease coding.Doctors use words like severe to modify a disease.It is easy to ignore the connotation of disease classification when coding,which results in information loss in severe illness.Using the concept of disease development chain to examine the process of disease development can improve the coding integrity of severe disease more effectively.