试析疾病编码的影响因素及改进措施  

Analysis on the Influence Factors and Improvement Measures of Disease Coding

作　　者：董艳红[1] 陈秀芳[1] 冯梦瑶 季宏波[1] 赵莉[1] 汪宁宁[1] 

机构地区：[1]黑龙江省医院病案统计科,黑龙江哈尔滨150036

出　　处：《中国继续医学教育》2016年第25期20-21,共2页China Continuing Medical Education

摘　　要：目的本文针对疾病编码正确性的影响因素进行初步探讨,并有针对性地提出改进措施。方法根据医院病案管理工作实际结合医院病案对疾病编码的影响因素进行分析。结果影响临床医生的主要影响因素主要为错误诊断、不准确填写病案首页等,编码人员由于不具备丰富的临床知识、对于电脑编码库依赖过度等因素影响了疾病编码的正确性。编码人员应在临床基础知识学习及专业水平方面不断提高,临床医生应对疾病编码的分类原则全面了解等都是改进编码准确性的主要措施。结论疾病编码的准确性需要临床医生、病案编码人员的细致工作及规范管理,准确的疾病编码对于有效利用医院病案具有十分重要的作用。Objective In this paper, This paper makes a preliminary study on the inlfuencing factors of the correctness of the disease coding, and puts forward some improvement measures. Methods According to the actual situation of hospital medical record management, the inlfuence factors of the disease code were analyzed.Results The diagnostic error, not accurate and complete medical record homepage are main factors influencing clinician, does not have the rich clinical knowledge, rely on computer code library too much are main factors affecting the personnel code. Coding personnel should be improved in the clinical basic knowledge learning and professional level. The main measures to improve the coding accuracy are the understanding of the classification principle of the disease codes and so on.Conclusion The accuracy of disease coding can not be separated from the detailed work and standardized management of clinical doctors and medical record coding personnel. Accurate disease coding plays a very important role in the effective use of hospital medical records.

关 键 词：疾病分类编码 病案管理 改进措施 

分 类 号：R197.3[医药卫生—卫生事业管理]