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随着军队《医院医疗信息管理系统》的推广应用,我院统计工作基本走上了正轨,但由于病案首页中诊断名称及顺序排列不当,仍然影响着统计质量。所以,临床医生全面地了解和掌握ICD—9的基本知识,正确使用ICD—9编码,是提高统计质量的一个前提。1 使用中存在的几个问题1.1 使用不规则的病名,致使编码不准确。有的医生以症状代病名或用方言写病名,不用ICD—9规范化的诊断术语,人为地造成许多疑难编码,直接影响到与统计质量有关的待诊率、诊断符合率、三日确诊率等指标。
With the promotion and application of the military “Hospital Medical Information Management System”, the statistical work of our hospital has basically gone on track, but due to the improperly arranged diagnostic names and the order, the statistical quality is still affected. Therefore, the clinician fully understands and masters the basic knowledge of ICD-9 and uses ICD-9 correctly, which is a prerequisite for improving statistical quality. 1 Several problems in use 1.1 The use of irregular disease names resulted in inaccurate coding. Some doctors use the name of the disease on behalf of the disease or use the dialect to write the name of the disease. They do not use ICD-9 standardized diagnostic terminology, artificially causing many difficult codes, directly affecting the rate of waiting for diagnosis related to the statistical quality, the diagnostic compliance rate, the three-day diagnosis rate, etc. index.