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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。
Objective To understand why clinicians fill in the diagnosis of the disease and choose the main diagnosis errors, and explore effective measures to improve the accuracy of the main diagnosis. Methods A retrospective survey of 1358 new cases of discharged medical records in our hospital in November 2013 was conducted according to the principles of major diagnostic writing. Statistics were made on whether the chief physician with major defects in diagnosis received ICD-related knowledge training for statistical analysis. Results The trained physician’s error rate was 7.47%, the untrained error rate was 33.51%, and the main diagnostic total defect rate was 14.51%. The difference was statistically significant (P <0.05) between trained and untrained patients. Conclusions The main reason for the major diagnostic errors is the lack of training of clinicians in the knowledge of ICD. It is suggested to increase the popularization of ICD-10 knowledge to clinicians and to fundamentally improve the accuracy of primary diagnosis.