重视主要诊断的选择 适应医保制度改革  

Attach Importance to Determination of Main Diagnosis to Conform to Requirement of Medical Insurance System Reform

作　　者：李伟光[1] 杨丽华 贾恩平[1] 

机构地区：[1]解放军北京军区总医院分院,北京市100026 [2]北京市建国门医院

出　　处：《中国医院统计》2001年第1期34-36,共3页Chinese Journal of Hospital Statistics

摘　　要：目的　了解在主要诊断选择中存在的问题及其对单病种费用的影响。方法　首先依据病案内容判断主要诊断的正确性 ,然后进行医疗质量及单病种费用的统计和分析。结果　在主要诊断的选择中存在着概念不清、人为拔高、错选它科疾病、诊断依据不充分及诊断名称不规范等问题。结论　主要诊断选择不当可致医疗质量统计和病种费用统计失真 ,这将影响医院管理者或卫生管理部门的决策 ,也影响着病案资源的利用和共享。Objective To understand the problem existing in main diagnosis determination and its influence on cost of single-type of disease. Methods Research on the correctness of main diagnosis in medical record archives and its relationship with medical cost by statistics and analysis. Results In determination of main diagnosis, some problems existed: confused concept, man induced raise, misdiagnosis, insufficient proof for diagnosis or nonstandard diagnosis name. Conclusion Incorrect determination of main diagnosis can lead to the mistakes of medical statistics and lack fidelity disease cost, which will affect policy decision of hospital managers or health management authorities as well as the use and share of medical record resources.

关 键 词：主要诊断 医疗保障制度 改革 

分 类 号：R44[医药卫生—诊断学]