疾病诊断在病案首页填写中的问题及对策  

The Problems and the Countermeasure of Disease Diagnosis Writing on the First Pages of Medical Records

作　　者：李磊[1] 刘桂芳[2] 侯桂丽[2] 

机构地区：[1]吉林大学中日联谊医院,长春市130031 [2]黑龙江省双城市中医院,双城市150100

出　　处：《中国医院管理》2002年第10期29-30,共2页Chinese Hospital Management

摘　　要：目的:为了减少疾病诊断在病案首页中的问题,提高国际疾病分类和统计工作的准确性。方法:回顾性总结3万多份病案首页中存在的问题,分析其原因。结果:疾病诊断在病案首页中的问题有:(1)疾病诊断名称不完整问题。(2)主要诊断与其他诊断书写不分主次问题。(3)手术后就诊的疾病诊断不确切问题。结论:加强临床医生和在校学生对国际疾病分类等有关知识的理解,提高编码员的专业知识水平及加强病案室与临床科室的交流是解决上述问题的关键。Objective To reduce the problems of disease diagnosis on the first pages of medical records and improve the accuracy of international classification of diseases and statistics. Methods Review and summarize the problems of 30, 000 medical records, and analyse their reasons. Results The problems of disease diagnosis on the first pages of medical records are: (1) The whole names of some disease diagnosis aren' t used. (2) Some disease diagnosis don' t differentiate what is primary from what is secondary. (3)Some postoperative disease diagnosis aren't precise. Conclusion The keys to the settlement of the problems lie in clinical doctors and medical students should strengthen their understanding of knowlege of international classification of diseases and the related fields, and coders must improve their levels of professional knowledge, and records rooms should strengthen an exchange with clinical departments.

关 键 词：问题 对策 疾病诊断 病案首页 ICD-10 病案管理 编码员 

分 类 号：R197.323[医药卫生—卫生事业管理]