摘要
采用按诊断检索和手术方式检索的方法检索病案首页信息数据库,探讨具有Q51和Q52编码的妇科生殖器畸形病案的主要诊断选择问题以及漏编码问题。利用检索数据库的方式可发现漏编、漏检以及主要诊断选择错误的问题。采用这种方法可以迅速找到编码错误的病案,提高工作效率以及数据检索的完整性和准确性,但是也会遗漏部分漏编码病案。明确疾病的主要诊断选择原则,提供自查自检漏编码问题的方法,可以提高病案编码的正确性,提高病案检索的查准率和查全率,为临床研究提供更全面、准确的数据基础。
By retrieving the name of diagnosis and operation in the medical records homepage information database, to investigate the problems in main diagnosis selection of coding represented by Q51 and Q52 of gynecology genitals malformation medical records, as well as the problem of missing encoding. We could find out problems of missing encoding, missing examination and mistaken selection of main diagnosis with the application of database retrieval. We could find out medical records with coding mistakes quickly by this method, improve work efficiency as well as accuracy and integrity of database retrieval, but would also missing some of medical records without coding. This paper identifies the principle of main diagnosis selection, and provides a method to check the leakage of encoding. The coders should improve the accuracy of encoding, and improve the retrieval precision and recall ratio, so as to provide comDrehensive and accurate data basis for clinical research.
出处
《中国病案》
2016年第3期29-32,共4页
Chinese Medical Record
关键词
主要诊断选择
漏编码
女性生殖器畸形
病案检索
Selection of main diagnosis
Missing encoding
Female genital malformation
Medical record retrieval
