基于ICD-10出院诊断问题分析与改进建议  

Analysis and Suggestions on Discharge Diagnosis Based on ICD-10

作　　者：许剑峰[1] 崔丽英[1] 朱焱华[1] 周岩[1] 孙明[1] 王文习[1] 

机构地区：[1]中国人民解放军白求恩国际和平医院,河北石家庄050082

出　　处：《中国卫生质量管理》2017年第4期34-36,共3页Chinese Health Quality Management

摘　　要：临床诊断与ICD分类脱节影响医院疾病编码及临床医师填写首页的准确性。医师在参考ICD-10填写病案首页出院诊断时存在的主要问题有疾病诊断名称不规范、主要诊断选择错误、出院诊断与病案内容不符、遗漏次要诊断等。提出应建立标准的临床字典录入库,构建培训制度及病案摘录研究制度,以提高编码准确性,助力于DRGs的推广实施。The dislocation between clinical diagnosis and ICD classification affects the hospital disease coding and the writting accuracy of the home page of medical record by clinician. The major problems of physician on writing the dis charge diagnosis on home page of medical record based on the ICD- 10 included unstandardized disease diagnosis name, wrong main diagnostic selection, unmatched discharge diagnosis and medical records, missing of secondary diagnosis etc. It was proposed to establish a standard clinical dictionary entry library, construct a training system and a case study system to improve the coding accuracy, and facilitate the implementation of DRGs

关 键 词：ICD-10 病案首页 出院诊断 

分 类 号：R197.323[医药卫生—卫生事业管理]