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目的探讨有关以术后再住院为主要诊断病案的编码问题,减少因工作人员的主观臆断将“XX术后”分类Z98.8(其他特指的手术后状态)的病案数量,从而提高疾病分类编码的质量。方法对本院2010年1月至2011年12月113份,以术后再住院为主要诊断的病案进行了研究分析。结果对这些病案进行了核对和重新编码。结论为了确保主要诊断的选择和编码的准确性,应加强编码员与医生之间的沟通,编码员对临床知识加强学习;临床医生对主要诊断的选择应加强培训。
Objective To explore the coding problems related to postoperative inpatient rehospitalization as the main diagnostic medical record and to reduce the number of medical records classified as Z98.8 (other special postoperative conditions) due to the subjective assumptions of staff and to increase The quality of the disease classification code. Methods The hospital from January 2010 to December 2011 113, to postoperative hospitalization as the main diagnosis of medical records were analyzed. As a result, these medical records were checked and recoded. Conclusion In order to ensure the accuracy of primary diagnosis and coding, communication between coder and doctor should be strengthened and coder should enhance clinical knowledge. Clinicians should strengthen their training on the choice of major diagnosis.