摘要
目的分析肺结核病D86.0疾病分类编码使用情况,提高D86.0疾病分类编码准确率。方法根据《疾病和有关健康问题的国际统计分类第十次修订本》分类原则,检索某院存在D86.0疾病分类编码的病历。结果 D86.0疾病分类编码的正确使用取决于医师的正确诊断,医师易混淆肺结核病与肺结节灶;以及编码员缺乏临床专业知识,阅读病历不充分,与医生沟通不畅两方面因素。结论加强对临床医师正确填写病案首页出院诊断的培训,普及编码员的临床知识,提高编码员对D86.0疾病分类编码的认识,确保D86.0疾病分类编码的正确使用。
Objectives To analyze the utilization situation of D86.0 diseases classification coding of sarcoidosis, and improve the accuracy rate of the classification of the disease. Methods According to the rules of ＂Tenth Revision of international statistical classification of diseases and related health problems＂, we retrieved all the medical records classified by the D86.0 classification of diseases. Results The proper utilization of the D86.0 classification of disease depended on the doctors＇ correct diagnosis and the correct classification of diseases by the encoder. Conclusions In order to insure the proper utilization of the D86.0 classification of diseases, we must enhance the training of clinical doctors on the correct filling of the discharge diagnosis on the front pages of medical records, popularize the clinical knowledge and improve the understanding of the D86.0 classification of disease of the encoder.
作者
赵钦花
Zhao Qinhua(Zibo Central Hospital in Shandong Province, Zibo 255036, Shandong Province, Chin)
出处
《中国病案》
2017年第7期29-31,共3页
Chinese Medical Record
