主要诊断填写缺陷的原因分析及对策

目的 了解临床医师填写疾病诊断、选择主要诊断错误的原因,探讨提高主要诊断准确性的有效措施.方法 回顾性调查我院2013年11月份的出院病历1358份新版病案首页,按主要诊断书写原则进行核查,统计主要诊断存在缺陷的主管医师是否接受过ICD相关知识的培训,作统计学分析比较.结果 经过培训的医师错误率为7.47％,未经培训的错误率为33.51％,主要诊断总缺陷率为14.51％,经过培训与未经培训相比较,差异具有统计学意义（P＜0.05）.结论 主要诊断错误的主要原因是临床医师缺乏ICD相关知识的培训.建议加强对临床医师进行ICD-10知识的普及,从根本上提高主要诊断的准确性.

Reason Analysis on Filling Defects of Principal Diagnosis and Relevant Countermeasure

Objective To understand the reasons on mistakes made by clinicians in filling diseases diagnosis and choosing principal diagnosis,and to explore the effective measures to improve the principal diagnosis.Methods A retrospective survey was performed on 1358 cases of new edition home pages in discharged medical records in November 2013 of our hospital,and conducted inspection according to the writing rules of principal diagnosis.To inspect the clinicians existing defects in principal diagnosis whether received ICD related knowledge training and make statistical analysis and comparison.Results The error rate of trained clinicians was 7.47％,while that of without training was 33.51％,the total defect rate of principal diagnosis was 14.51％,the difference was statistically significant （P ＜ 0.05） after comparison between training and without training.Conclusions The main cause of errors in principal diagnosis was the lack of ICD related knowledge training for clinicians.We should strengthen the popularization of ICD-10 knowledge among clinicians,and improve the accuracy of principal diagnosis fundamentally.