减少疾病诊断在病案首页中问题的几点建议  

Problems of diagnoses in the front sheet

作　　者：李磊[1] 

机构地区：[1]吉林大学中日联谊医院,130031

出　　处：《中国医院》2002年第11期52-54,共3页Chinese Hospitals

摘　　要：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,回顾性总结3万多份病案首页中存在的问题有:(1)疾病诊断名称不完整。(2)手术后就诊的疾病诊断不确切。(3)主要诊断与其他诊断书写不分主次,提出加强临床医生和在校医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。The author has reviewed more than 30 thousands of medical records and find the problems as the following in the front sheets: (1) incomplete terms of diagnosis, (2) improper diagnoses of the operation cases, (3) no mark on the main diagnosis. The author consider that it is the key to solve the above problems by educating the clinical physicians and medical students in International Classification of Diseases, and improving the occupational level of the coders, and facilitating the communication between coders and physicians.

关 键 词：疾病诊断 病案首页 ICD-10 编码员 

分 类 号：R197.322[医药卫生—卫生事业管理]