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病案作为记录患者医疗活动的档案,其书写质量直接影响着疾病分类的准确性,临床医师由于不熟悉疾病分类或手术分类的编码规则,经常出现主要诊断选择不正确、出院诊断与病理诊断不相符、手术名称不准确等问题,这类问题常会导致编码的错误。为提高编码的准确性,编码人员应加强临床医师国际疾病分类相关知识和疾病诊断书写的培训,努力学习临床医学知识、不断提高自身素质以及专业知识水平。只有临床医师和病案编码人员的共同努力,才能保证疾病分类和手术操作分类的准确性,才能更好的为医疗、教学、科研服务。
Medical records as a record of medical records of patients, the writing quality of a direct impact on the accuracy of the classification of the disease, clinicians are not familiar with the classification of diseases or surgical classification of coding rules, often the main diagnostic options are not correct, discharge diagnosis and pathological diagnosis does not match , Surgical name is not accurate and other issues, such problems often lead to coding errors. In order to improve the accuracy of coding, the coder should strengthen the clinician’s training in the knowledge of international disease classification and disease diagnosis, strive to learn clinical medicine, and constantly improve their own quality and professional knowledge. Only the joint efforts of clinicians and medical record coders can ensure the accuracy of the classification of diseases and the classification of surgical operations in order to better serve the medical, teaching and scientific research.