摘要
按照梗阻性分娩的定义和导致梗阻性分娩的主要原因,结合临床实际病例展开论述,阐述梗阻性分娩相关疾病的编码原则。分析梗阻性分娩相关疾病编码错误的原因,主要包括产科医师对梗阻性分娩诊断认识不清?没有充分认识到病案首页数据质量的重要性?对住院病案首页数据填写质量规范不熟悉?不了解产科主要诊断的选择原则;编码人员对梗阻性分娩的概念掌握不扎实;产科上级医师未能充分发挥对病案首页的检查与指导作用。提出了提高梗阻性分娩编码正确率的措施,包括:加强与产科病历书写医师的沟通,医院管理部门加强疾病编码相关专业培训,提高医师对疾病编码的认识;病案编码人员对存在梗阻性分娩高危因素病历进行认真细致地回顾,发现遗漏诊断及时予以补充完善;医院加大对病案科的投入,加快编码队伍的建设,保证编码人员有充足的时间进行病历回顾,提高编码正确率。旨在提高产科梗阻性分娩相关疾病编码的正确率。
The coding principles of obstructive delivery-related diseases are described according to the definition and the main causes of obstructive delivery, and it was combined with the actual clinical cases. The reasons for the coding errors of obstructive delivery-related diseases were analyzed and they included： Obstetricians were unclear about the diagnosis of obstructive delivery. Obstetricians did not fully understand the importance of data quality on the first page of the medical record. Obstetricians were not familiar with the quality standards of inpatient records and obstetric major diagnostic selection principles. Coders do not grasp of the concept of obstructive delivery clearly. The superior obstetricians do not play important role in examination and guidance of the first page of the medical record. The measures which were proposed to improve the correct rate of obstructive delivery included： The coders strengthen the communication with obstetricians. The hospital management departments strengthen professional training in disease coding, and improve doctors＇ understanding of disease codes. The coders reviewed the medical records with high risk of obstructive delivery carefully, and supplement the omission diagnosis in time. The hospital management departments increased investment in the medical record department, accelerate the construction of the coding team, ensure the code personnel had sufficient time to review the medical records to improve the coding accuracy. The aim is to improve the correct rate of obstructive delivery-related diseases in obstetrics.
作者
赵会林
Zhao Huilin(Beijing Maternity Hospital Affiliated to Capital Medical University,Beijing 100026,China)
出处
《中国病案》
2018年第10期20-22,共3页
Chinese Medical Record
关键词
梗阻性分娩
疾病编码
分析
Obstructive delivery
Disease coding
Analysis
