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病人到医院就医情况复杂,诊疗结束或出院时往往具有多个诊断,在多个诊断中正确选择主要诊断进行疾病分类,对国家卫生管理的宏观调控、疾病信息的收集统计、医院管理的经营决策、医疗费用的核算赔付等等都具有十分重要的意义。而实际操作中,由于临床医师误选主要诊断,疾病编码人员对疾病分类规则又掌握不够时,常常会导致编码偏差,对医院医疗质量造成影响。本文列举5个典型案例,对主要诊断进行讨论分析和疾病编码。
Patients to the hospital for medical treatment is complicated, the end of diagnosis or discharge often have multiple diagnoses, the correct diagnosis of multiple diagnoses in the correct diagnosis of the disease classification, the macro-control of national health management, disease information collection and statistics, hospital management and management decisions , Medical expenses accounting and so on are all of great significance. In practice, due to clinicians misdiagnosing the main diagnosis, the disease coding staff to grasp the rules of the disease is not enough, often lead to coding bias, the impact on the quality of hospital medical care. This article lists five typical cases, to discuss the main diagnosis and disease coding.