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目的了解医生选择主要诊断的准确性与患者病情有无关系,分析造成错误的原因,探讨提高主要诊断准确性的有效措施。方法回顾性调查1000份新版首页,按主要诊断选择原则进行核查,分别统计主要诊断所对应的入院病情、有无转科、各个病例分型的主要诊断选择正误的情况,作统计学分析比较。结果主要诊断选择错误率为7.70%;有转科病例主要诊断选择错误率高于无转科者,差异有显著性(χ2=14.04,P<0.01);病例分型C+D型的主要诊断选择错误率高于A+B型,差异有统计学意义(χ2=26.89,P<0.01)。结论主要诊断错误的原因主要是由于临床医师缺乏国际疾病分类知识,且对选择主要诊断的重要性认识不足。改进措施关键是加强继续教育,让医师充实有关ICD的知识,并自觉重视正确选择主要诊断;提高编码员的业务素质。
Objective To understand the relationship between the accuracy of the primary diagnosis and the patient’s condition by the doctors, analyze the causes of the errors and discuss the effective measures to improve the accuracy of the primary diagnosis. Methods A retrospective survey of 1000 new version of the home page, according to the principle of the main diagnostic options for verification, respectively, statistics of the main diagnosis of the corresponding hospital admissions, with or without transcranial, the main diagnosis of each case is correct, for statistical analysis. Results The main diagnostic error rate was 7.70%. There was a significant difference between the two groups (χ2 = 14.04, P <0.01). The main diagnosis of case type C + D The error rate of selection was higher than A + B type, the difference was statistically significant (χ2 = 26.89, P <0.01). Conclusions The main causes of misdiagnosis are mainly due to clinicians lacking knowledge of international disease classification and lack of understanding of the importance of choosing the primary diagnosis. The key to improvement measures is to strengthen continuing education so that doctors can enrich the knowledge about ICD and consciously attach importance to the correct choice of the main diagnosis and improve the professional quality of coders.