病案首页在线质控及ICD编码构想  

Online Quality Control and ICD Coding Idea of the Front Sheet of Medical Record

作　　者：林海丽[1] 刘克新[1] 保鹏飞[1] 

机构地区：[1]解放军总医院,北京市100853

出　　处：《中国病案》2012年第6期18-19,共2页Chinese Medical Record

摘　　要：若能在病案归档前对病案首页进行质控和ICD编码,则能提前发现首页填写错误并及时通知医师修改,既确保了归档后病案没有修改过的痕迹,也方便了临床医生,还提高了病案管理的工作效率。这一构想完全可以通过现有的医院局域网添加相关程序完成,根据首页项目逻辑关系,设置计算机自动判断填写缺陷,通过医院局域网,实现人机对话在线检查填写缺陷。实现这一构想将改变以往病案首页质控的工作方式,是病案管理工作的一个重大改革。The filling error of the front sheet can be found and the doctors can be informed to modify it if quality control and ICD coding could be done before filing the front sheet. It not only ensures that medical records without modify traces after filling, but also convenient for clinical doctors and improve the efficiency of the medical records management. The idea can be realized completely through existing hospital LAN and relevant program. Fill out defects can be judged automatically by the computer according to the logic relationship of front page items. Online defects examine can be achieved by hospital LAN. The realizing of the ideal is a major reform of medical record management which will change the working pattern of quality control of front sheet.

关 键 词：质量控制 病案首页 ICD编码 

分 类 号：R197.3[医药卫生—卫生事业管理]