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目的探讨主要诊断编码的选择,提高疾病分类的质量。方法回顾性调查我院2008年1月至2010年6月325例以症状或体征为主要诊断编码的病案。结果诊断作出之前病人已出院、转院、死亡220例,占67.69%,病因明确医师以症状、体征作为主要诊断,而编码员仍依赖病案首页的诊断分类编码100例,占30.77%,编码员未详细查阅病案资料导致编码错误5例,占1.54%。结论编码员仅依赖医生主要诊断的填写进行编码是导致错误的主要原因,应加强临床医师ICD知识的培训、建立健全编码员管理制度,以保证编码的准确性。
Objective To explore the choice of the main diagnostic coding and improve the quality of disease classification. Methods A retrospective survey of our hospital from January 2008 to June 2010 325 cases of symptoms or signs as the main diagnostic coding case. Results Before the diagnosis was made, 220 patients were discharged, transferred and died, accounting for 67.69%. The etiology of the patients was mainly diagnosed by symptoms and signs, while the coder still relied on the diagnosis of the first page of the medical record for 100 cases, accounting for 30.77% Detailed access to medical records led to coding errors in 5 cases, accounting for 1.54%. Conclusions The coder only relied on the doctor ’s main diagnosis to fill in the coding is the main reason leading to error. The clinician should strengthen the training of ICD knowledge and establish and improve the coder management system to ensure the accuracy of coding.