325例以症状或体征作为主要诊断编码的分析  

Analysis on 325 Medical Records with Symptoms and Signs as the Primary Diagnostic Codes

作　　者：王岚[1] 李红[1] 

机构地区：[1]宁夏回族自治区人民医院病案室,银川市750021

出　　处：《中国病案》2011年第10期39-40,共2页Chinese Medical Record

摘　　要：目的探讨主要诊断编码的选择,提高疾病分类的质量。方法回顾性调查我院2008年1月至2010年6月325例以症状或体征为主要诊断编码的病案。结果诊断作出之前病人已出院、转院、死亡220例,占67.69%,病因明确医师以症状、体征作为主要诊断,而编码员仍依赖病案首页的诊断分类编码100例,占30.77%,编码员未详细查阅病案资料导致编码错误5例,占1.54%。结论编码员仅依赖医生主要诊断的填写进行编码是导致错误的主要原因,应加强临床医师ICD知识的培训、建立健全编码员管理制度,以保证编码的准确性。Objective To investigate the choice of the primary diagnosis of medical record,improve the quality of diseases classification.Methods Retrospectively survey 325 medical records with symptoms and signs as the primary diagnosis codes in our hospital from January 2008 to June 2010.Results There were 220 patients who have been discharged,transferred and deceased before the diagnosis were made,accounting for 67.69%.Disease with clear cause but physicians made the symptoms and signs as the primary diagnosis,while coders still coded them dependent on the diagnostic categories of the front sheets were 100 cases,accounting for 30.77%.There were 5 cases which the coders made error codes without accessing to medical records,accounting for 1.54%.Conclusion The main reason for coding errors is the coders solely rely on the primary diagnosis that doctors fill in.ICD knowledge train should be enhanced for clinicians,and a sound coder management system should be established to ensure the accuracy of coding.

关 键 词：症状 体征 主要诊断编码 

分 类 号：R197.3[医药卫生—卫生事业管理]