正确选择疾病的主要诊断  

Choosing the Chief Diagnosis Correctly

作　　者：黄英[1] 蒋伟[1] 孟兵 

机构地区：[1]解放军总医院病案科

出　　处：《中国病案》2005年第6期39-40,共2页Chinese Medical Record

摘　　要：主要诊断选择规则模糊、诊断范围过大与病理诊断不符、诊断顺序不对,是常见的诊断书写不规范之处,分析其原因其一可能《诊断学》与ICD-10的要求有一定的差别,其二病案质量检查对诊断符合率的过高要求,使医生对入院诊断、初步诊断、最后诊断选用较笼统的名称填写或用临床症状替代主要诊断。临床医生学习国际疾病分类、主要诊断选择,进行病历书写的岗前培训、强化病历的三级检查制度及提高编码人员临床诊断的分类能力,是有效的防范措施。Firstly, the most common unsuitable clinical chief diagnosis for ICD-10 (International classification of diseases-10 ) are ambiguity, over standa rd, wrong diagnosis, mismatched pathological and wrong ordered diagnosis. The re asons might be associated with the inconsistence of diagnosis and misunderstandi ng about ICD-10. Secondary. the unreasonable high consistent ratio to the doctor s, which makes the misunderstanding on the original, the final and the chief dia gnoses. Thirdly, the doctors are lack of the understanding principle of how to s elect the chief diagnosis. In order to reduce these mistakes, pre-job training f or the case writers, three-level report checking are important and effiective.

关 键 词：主要诊断选择 ICD-10 国际疾病分类 书写不规范 《诊断学》 诊断符合率 临床医生学 诊断不符 诊断范围 诊断顺序 病案质量 入院诊断 初步诊断 临床症状 名称填写 岗前培训 病历书写 临床诊断 编码人员 检查制度 防范措施 

分 类 号：R197.3[医药卫生—卫生事业管理]