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世界卫生组织和我国卫生部规定,对病例采用单一原因分析。即当就诊者存在一种以上的疾病损伤或情况时需选择其中一个主要情况进行分类统计。病例主要情况的选定是由临床医师负责填于病案首页的出院诊断栏内(列为第一诊断),因此疾病分类编码的准确真实有赖于临床医生的正确诊断与填写,而分类编码的准确性直接影响疾病分类统计报表的质量。
The World Health Organization and China’s Ministry of Health stipulate a single-cause analysis of cases. That is, when there is more than one illness or condition in the patient, one of the major cases should be selected for the classification statistics. The main case of the case selected by the clinician is responsible for filling the first page of the hospital diagnosis of illness diagnosis column (as the first diagnosis), so the exact classification of disease coding depends on the clinician’s correct diagnosis and fill in, and accurate classification coding Sex directly affects the quality of disease classification statistics.