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随着各级医院信息化的普及,越来越多的医院将标准编码库与诊断和手术操作名称关联,编码员或医师过度依赖标准编码库,直接套用标准库中类似名称进行ICD编码,导致编码准确性降低。笔者所在研究团队采用优化扩展编码库的方式,增加电子编码核对信息,免除工具书翻阅查找步骤;增加编码员提示,确保加码准确应用;增加医师指引,提高临床医师对疾病分类的理解。结合计算机简化编码流程,确保疾病分类工作高效率、高质量。
With the popularization of informatization at all levels of hospitals, more and more hospitals associate the standard code base with the name of the diagnostic and surgical operation. The coder or physician over-relies on the standard code base and directly applies ICD codes with similar names in the standard base, resulting in Reduced coding accuracy. The author’s research team adopted the method of optimizing the extension of the code base to increase the electronic code check information and avoid reading the reference book through the search steps; increasing the coder prompts to ensure the accurate application of the code increase; and increasing the physician’s guidelines to improve the clinician’s understanding of the classification of the diseases. Combine the computer to simplify the coding process and ensure the high efficiency and high quality of the disease classification.