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目的 了解在主要诊断选择中存在的问题及其对单病种费用的影响。方法 首先依据病案内容判断主要诊断的正确性 ,然后进行医疗质量及单病种费用的统计和分析。结果 在主要诊断的选择中存在着概念不清、人为拔高、错选它科疾病、诊断依据不充分及诊断名称不规范等问题。结论 主要诊断选择不当可致医疗质量统计和病种费用统计失真 ,这将影响医院管理者或卫生管理部门的决策 ,也影响着病案资源的利用和共享。
Objective To understand the problems that exist in the main diagnostic options and their impact on single-species costs. Methods According to the contents of the medical record, the correctness of the main diagnosis is firstly determined, and then the statistics and analysis of the medical quality and the cost of the single disease are performed. RESULTS: Among the main diagnostic options, there were problems such as unclear concepts, artificially high elevations, incorrectly selected diseases, inadequate diagnostic criteria, and non-standard diagnostic names. Conclusion Improper diagnosis and selection may result in distorted medical quality statistics and disease cost statistics, which will affect decisions of hospital administrators or health management departments, and also affect the use and sharing of medical resource resources.