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目的分析医师填写病案首页疾病诊断和编码的情况,探讨医师进行疾病编码方法的可行性。方法回顾性调查和分析我院2012年1月至2013年6月病案首页医师填写疾病名称和疾病编码的状况。结果 22035份住院病案首页中疾病名称填写不规范、主要诊断选择和疾病编码错误比例为7.8%。结论目前情况下暂不适宜临床医师承担疾病编码工作;加强临床医师了解ICD-10知识,促进病案编码员掌握ICD-10编码原则,确保疾病编码的准确性。
Objective To analyze the condition of physicians filling out the first case of disease diagnosis and coding and discussing the feasibility of the physician to carry out the disease coding method. Methods A retrospective survey and analysis of our hospital from January 2012 to June 2013 medical records Home Physicians fill in the name of the disease and the status of disease codes. Results 22,035 inpatient medical records in the home page fill in the name of non-standard, the main diagnostic options and disease coding error ratio of 7.8%. Conclusions In the current situation, it is not suitable for clinicians to undertake disease coding at present. It is necessary to strengthen clinicians’ understanding of ICD-10 knowledge and promote case coders to master ICD-10 coding principles and ensure the accuracy of disease coding.