外科手术病历书写与医疗保险病种付费的关系  

THE RELATION BETWEEN OPERTION RECORD WRITING AND SINGLE DISEASE FEE SYSTEM OF MEDICAL INSURANCE

作　　者：李建炜[1] 林洁中[1] 陈小花[1] 曾桂珍[1] 

机构地区：[1]湛江中心人民医院,广东湛江524037

出　　处：《现代医院》2012年第9期132-133,共2页Modern Hospitals

摘　　要：通过理论向外科医师介绍国际疾病分类(ICD-9-CM-3)编码的原则及ICD-9-CM-3编码与单病种付费的关系、国外已开展DRGs医保预付费的经验教训,使临床医师了解手术操作记录及手术操作名称是单病种医保付款的重要依据之一,外科手术病历书写不仅要详实的反映诊疗过程,包括术前、术中和术后的每一项记录,而且应符合单病种付费,满足ICD-9-CM-3编码的需要,达到提高编码质量的目的,为DRGs在我国的推广打下基础。This essay declares that ICD - 9 - CM - 3 surgery operation coding is one of the basis for Single Disease Fee System. To achieve the goal of improving the quality of encoding, surgeon should record every detail in operation record writing fully and accurately, not only includes the process during diagnosis and treatment but also conform to the Single Disease Fee System and meet the demands of ICD - 9 - CM - 3 coding. To show the principles of ICD - 9 - CM - 3 surgery operation coding, its relationship with Single Disease Fee System and the lessons of med- ical insurance Prospective Payment System, of which the DRGs in foreign countries is based on, in order to allow Sur- geon realize that surgery operation records and operation names are important basis of Single Disease Fee System, and ICD - 9 - CM - 3 coding is the basis of medical insurance payment. This essay provides a theoretical basis for popu- larize DRGs in China.

关 键 词：手术病历书写 ICD-9-CM-3 单病种付费 

分 类 号：R197[医药卫生—卫生事业管理]