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ICD-10的推广使用促进了病案管理的规范化及标准化,使我院病案管理工作基本走上了正轨。由于疾病的复杂性,病案首页中诊断名称很多,排列顺序不妥当,病案统计工作人员对 ICD-10知识的缺乏,仍然影响着疾病分类统计质量,所以使广大医师和统计工作人员掌握 ICD-10的基本知识,正确使用 ICD-10的编码,提高编码的准确率是提高疾病分类统计质量的一个重要前提。1 ICD-10编码中存在的问题1.1 临床医师对书写诊断的责任心不强诊断书写不规范,用症状代替病名,不用 ICD-10的规范化诊断术语,例如,
The promotion and use of ICD-10 has promoted the standardization and standardization of medical record management, and has made the management of medical records in our hospital basically on the right track. Due to the complexity of the disease, there are many diagnosed names on the front page of the medical record, and the sequence is not appropriate. The lack of knowledge of the ICD-10 in the medical record statistics staff still affects the quality of disease classification statistics, so that the majority of physicians and statisticians grasp the ICD-10. The basic knowledge, correct use of ICD-10 coding, and improved coding accuracy are an important prerequisite for improving the statistical quality of disease classification. 1 Problems in ICD-10 coding 1.1 The clinician’s sense of responsibility for writing diagnosis is not strong. Diagnostic writing is not standardized. Instead of the disease name with symptoms, ICD-10 standard diagnostic terms are not used. For example,