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目的从编码角度探讨提高死亡报告卡疾病信息准确性的方法。方法采用回顾性调查方法对456份死亡报告卡进行列表统计。结果死亡科别、新生儿体重、就诊情况、诊断书写等均可影响报告卡疾病信息的准确性。结论提高医生对死亡报告卡的书写能力.同时将编码与病案同步,可以降低报告卡疾病信息的失误率。
Objective To explore the method of improving the accuracy of death reporting card disease information from the perspective of coding. Methods A retrospective survey method was used to count 456 death report cards. Results The death department, neonatal body weight, visit status, diagnosis and writing can all affect the accuracy of the report card disease information. 2. Conclusion Increased doctors’ ability to write death report cards. At the same time, synchronizing the coding with the medical record can reduce the error rate of the report card disease information.