产科疾病诊断编码案例分析  

Cases Analysis on Disease Diagnosis Coding of Obstetrics

作　　者：古莲香[1] 邢庆芳[1] 叶演红[1] 黄慧[1] 

机构地区：[1]深圳市龙岗区人民医院信息科

出　　处：《中国病案》2012年第7期31-32,共2页Chinese Medical Record

摘　　要：在审查校正编码过程中发现,编码人员只看病案首页,不详细阅读、分析病案资料,因此造成编码错误。本文根据国际疾病分类原则选择最容易出现错误的四个案例进行分析,探讨产科诊断编码,指导编码人员准确编码,提高产科诊断分类质量。文章提示,解决产科编码问题应综合分析各并发症之间的关系,加强与临床医师的沟通,耐心细致阅读各种检查结果及病案描述,才能保证编码的准确性和科学性。During evaluation and correction coding, it is found out that staffs who give coding only reading the frontage of medical record without careful reading and analysis about them＇ which cause coding error. According to international disease classification principles, four cases that most easily occurs error are selected to analyze in order to discuss obstetric diagnosis coding and to instruct correct coding, for improving obstetric diagnosis classifi- cation quality. To solve the coding problems of obstetrics, we should have comprehensive analysis on the relationship among different complication and strengthen the communication with clinical physicians with carefully reading examination and medical record, which can ensure the accuracy and science of coding.

关 键 词：产科诊断 疾病分类 案例分析 

分 类 号：R197.3[医药卫生—卫生事业管理]