论文部分内容阅读
目的鼓励临床医生编码疾病主要诊断,提高医院疾病主要诊断编码正确率。方法分析2012年1月-2013年6月临床医生疾病主要诊断编码情况,了解实行临床治疗组长负责疾病编码,病案科编码人员针对各临床科室疾病特点对临床医生进行国际疾病分类知识的介绍,并与临床医生就疾病编码问题进行实时沟通与交流的方法能否提高疾病主要诊断编码正确率。结果全院临床医生主要诊断编码率从94.081%提高至98.301%,编码正确率从75.824%下降至67.483%,最后达到81.893%。结论鼓励临床医生编码疾病主要诊断,实行临床治疗组长负责制,可提高主要诊断编码的准确性,加强临床科室与病案科之间的交流,有助于疾病编码质量得到持续不断的改进。
Objective To encourage clinicians to code the main diagnosis of diseases and to improve the accuracy of the main diagnosis code of hospital diseases. Methods From January 2012 to June 2013, the author analyzed the major diagnosis codes of clinicians and learned about the implementation of the clinical treatment team leader responsible for disease coding. The staff of the coding department introduced clinicians’ knowledge of international disease classification according to the characteristics of each clinical department, And with clinicians on disease coding problems in real-time communication and exchange methods can improve the accuracy of the disease diagnosis code. Results The rate of primary diagnosis of clinicians increased from 94.081% to 98.301%, and the correctness of coding rate decreased from 75.824% to 67.483% and finally to 81.893%. Conclusions Encouraging clinicians to code the main diagnosis of diseases and implementing the responsibility system of clinical team leader can improve the accuracy of the main diagnostic codes and enhance the communication between clinical departments and medical records department so as to help the quality of disease codes to be continuously improved.