摘要
随着各级医院信息化的普及,越来越多的医院将标准编码库与诊断和手术操作名称关联,编码员或医师过度依赖标准编码库,直接套用标准库中类似名称进行ICD编码,导致编码准确性降低。笔者所在研究团队采用优化扩展编码库的方式,增加电子编码核对信息,免除工具书翻阅查找步骤;增加编码员提示,确保加码准确应用;增加医师指引,提高临床医师对疾病分类的理解。结合计算机简化编码流程,确保疾病分类工作高效率、高质量。
With the popularization of hospitals＇ information, more and more hospitals link up the standard encoding library and the name of diagnosis, operations and procedures. Coders or doctors are prompted to rely too much on the standard encoding library. Apply mechanically a similar name of standard encoding library to coding,accuracy rate is decreased. Our research team is considering the way to solve this problem by optimizing the encoding library. By added the encoding check information, read and look up steps are omitted. By added the coder tips, extended codes can be ensure accurate. By added the doctor guidelines, doctors improve the understanding of the ICD. Combining with the computer to simplify the encoding process, we can improve the efficiency of encoding work while reducing the error rate.
出处
《中国病案》
2016年第6期35-37,共3页
Chinese Medical Record
