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目的探讨病案书写质量对疾病编码正确性的影响。方法总结分析病案书写质量缺陷造成疾病编码错误的原因,提出有效改正措施。结果病案首页疾病诊断名称书写不统一、不标准,病史内容和体格检查书写不准确,病程记录、手术记录、医嘱内容不完整,根本死亡原因选择错误或不填写,特殊检查操作名称填写不全,辅助检查报告单不归入病案等是导致疾病编码和手术操作编码错漏的重要因素。加强病历书写人员的培训,提高病案质量检查人员和编码人员的自身素质,加强ICD-10及ICD-9-CM-3知识的学习,争取计算机软件的支持是提高编码质量的有效措施。结论病案书写质量是疾病准确编码的基础,疾病编码是病案质量的表现。
Objective To explore the impact of the quality of medical record writing on the correctness of disease coding. Methods To summarize and analyze the causes of the disease coding errors caused by the quality defects of medical records and put forward effective corrective measures. The results of medical records Home Disease diagnosis Name Writing is not uniform, not standard, medical history and physical examination is not accurate writing, course records, surgical records, doctor’s advice is incomplete, the root cause of death is wrong or not filled in, special inspection operation name incomplete, auxiliary Check report is not included in the medical record and other diseases is caused by encoding and surgical coding error is an important factor. Strengthening the training of medical records writers, improving the quality of medical record inspectors and coders, and enhancing the learning of ICD-10 and ICD-9-CM-3 knowledge, and striving for the support of computer software are effective measures to improve the coding quality. Conclusion The quality of medical record writing is the basis of accurate coding of the disease. Disease coding is the manifestation of medical record quality.