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目的通过分析患者本次住院就医的主要原因,探讨骨折内固定术后的分类编码。方法对某院2014年1月1日-2015年12月31日出院诊断为骨折内固定术后的342份病案进行回顾性分析,按照国际疾病分类原则,对骨折内固定术后进行编码。结果 342份诊断为骨折内固定术后的病案中,228份编码错误,错误率达66.67%,导致错误编码的主要因素是编码员和临床医师有效沟通不够。结论骨折内固定术后是不规范诊断名称,编码员在面对诊断骨折内固定术后时,要认真阅读分析病案,多与临床医师及同事进行沟通和讨论,按照国际疾病分类原则,提高编码水平。同时还应培训医师,促使其规范书写疾病诊断名称。
Objective To analyze the main reason of patients hospitalized for medical treatment and discuss the classification and coding after fracture internal fixation. Methods A retrospective analysis was performed on 342 medical records of a hospital diagnosed as internal fixation after fracture fixation from January 1, 2014 to December 31, 2015. The internal fixation of the fracture was coded according to the international classification of diseases. Results Among the 342 cases diagnosed as fracture fixation, 228 were wrongly coded and the error rate was 66.67%. The main factor leading to wrong coding was the insufficient communication between coder and clinician. Conclusions After fracture fixation, non-standard diagnosis name is given. After coding fracture fixation, the coder should carefully read and analyze the medical record and communicate and discuss with clinicians and colleagues. According to the international classification of diseases, Level. At the same time should also train physicians, prompting its normative written disease diagnosis name.