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目的:探索更多满足DRGs正确上报的途径。方法:ICD-10编码是病案管理工作中一项较难掌握的技能,文章展现了按照国际疾病分类主要诊断编码选择原则和临床对疾病的认识来判断主要诊断的选择,以及确定主导词从而正确查找合理编码。结果:编码员对疾病的正确认识,与临床医师的沟通和编码员之间的讨论,以及编码员的工作态度和院领导对编码工作的重视决定了编码的正确率。结论:编码员阅读病历、熟练掌握ICD-10编码原则、具有良好的医学基础知识和沟通能力是保证编码质量的关键。
Objective: To explore more ways to satisfy the correct reporting of DRGs. Methods: ICD-10 coding is a difficult skill in case management. The article shows the choice of the primary diagnosis in accordance with the principle of selection of the main diagnostic codes and clinical knowledge of the disease in the International Classification of Diseases and the correctness of the key words Find a reasonable code. Results: Correct understanding of disease coders, communication with clinicians and discussing with coders, and work attitude of coders and the leadership of hospital leaders in coding work determine the correctness of coding. Conclusion: The coder reading the medical record and mastering the principle of ICD-10 coding has the good medical basic knowledge and communication ability is the key to ensure the coding quality.