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主要诊断的选择是对每一病例准确分类编码的关键,正确与否直接影响着国家对疾病统计数据的收集、医疗费用的结算理赔、医院的经营管理、病案首页疾病诊断的分类编码和科研数据收集。病案首页诊断描述不完整,是临床医师常犯的错误,这种误差将直接影响分类编码的准确性。疾病编码人员不应仅依赖病案首页所提供的诊断进行分类编码,应负起责任核实把关,参阅病案实际内容,确定完整诊断后再行编码。通过4例典型病案,对主要诊断确定以及如何编码进行分析讨论。
The main diagnostic choice is the key to accurate classification and coding of each case, the correct or not directly affects the national collection of disease statistics, settlement of medical expenses claims, the hospital’s management, medical record classification and coding of disease diagnosis data collect. Incomplete diagnosis of the first page of medical records, clinicians often make mistakes, this error will directly affect the accuracy of classification codes. Disease coding staff should not only rely on the diagnosis provided by the first page of the case classification code, should take the responsibility to verify the gatekeeper, refer to the actual content of the case, to determine the complete diagnosis and then coding. Through the 4 cases of typical medical records, the main diagnosis and coding and analysis of how to discuss.