一、病案首页内容的完整性与准确性 (一)医生填写诊断时应尽量准确 由于输入微机的疾病名称与手术名称均来自病案首页,正确书写疾病诊断和手术名称是做好疾病索引和疾病分类统计的关键,因此临床医生在填写出院诊断时应力求符合ICD分类的要求,采用以病因为主,解剖部位、临床表现、病理改变为辅的混合分类轴心,选择对健康危害最大,花费医疗精力最多、住院时间最长的、重点治疗的疾病为主要诊断,以确保编 First, the integrity of the contents of the first page of the case and accuracy (A) the doctor should fill in the diagnosis should be as accurate as possible Enter the name of the computer and the name of the surgery are from the medical record home page, the correct written disease diagnosis and surgical name is done disease index and disease classification Statistics, the clinician should fill out the discharge diagnosis should be consistent with the ICD classification requirements, using the main cause of the anatomy, clinical manifestations, pathological changes, supplemented by the mixed classification axis, choose the most health hazards, medical expenses The most energetic, longest hospital stay, the focus of treatment of the disease as the main diagnosis to ensure that the series