| 病案书写质量对疾病编码的影响 |
| |
| 引用本文： | 杨翔宇,郑琳,刘克新.病案书写质量对疾病编码的影响[J].中国病案,2011,12(12):16-17. |
| |
| 作者姓名： | 杨翔宇 郑琳 刘克新 |
| |
| 作者单位： | 解放军总医院病案管理科,北京市,100853 |
| |
| 摘 要： | 目的探讨病案书写质量对疾病编码正确性的影响。方法总结分析病案书写质量缺陷造成疾病编码错误的原因,提出有效改正措施。结果病案首页疾病诊断名称书写不统一、不标准,病史内容和体格检查书写不准确,病程记录、手术记录、医嘱内容不完整,根本死亡原因选择错误或不填写,特殊检查操作名称填写不全,辅助检查报告单不归入病案等是导致疾病编码和手术操作编码错漏的重要因素。加强病历书写人员的培训,提高病案质量检查人员和编码人员的自身素质,加强ICD-10及ICD-9-CM-3知识的学习,争取计算机软件的支持是提高编码质量的有效措施。结论病案书写质量是疾病准确编码的基础,疾病编码是病案质量的表现。
|
| 关 键 词： | 病案书写质量 疾病编码 |
The Effect of Writhing Quality of Medical Records on Disease Coding |
| |
| Yang Xiangyu,Zheng Lin,Liu Kexin.The Effect of Writhing Quality of Medical Records on Disease Coding[J].Chinese Medical Record,2011,12(12):16-17. |
| |
| Authors: | Yang Xiangyu Zheng Lin Liu Kexin |
| |
| Affiliation: | Yang Xiangyu,Zheng lin,Liu Kexin,Department of Medical Records Management,the General Hospital of the PLA,Beijing 100853,China |
| |
| Abstract: | Objective to discuss the effect of the medical record writing quality on the correctness of disease coding.Methods This paper summarizes and analyzes the error of diseases codes caused by medical record writing quality defects,proposing effective corrective measures.Results The important factors leading to wrong or loss of disease coding and operation coding are that non-uniform and non-standard diagnosis in front sheet of medical records;inaccurate medical history and physical examination;incomplete course... |
| |
| Keywords: | Quality of medical record writing Disease coding |
| 本文献已被 CNKI 维普 万方数据 等数据库收录！ |
|
