摘要
对影响肿瘤编码的准确性因素进行分析,影响肿瘤编码准确性的主要因素是医师的书写不规范,编码员的素质水平参差不齐,病理诊断与主要诊断不相符,以及对肿瘤的主要诊断选择不准确。针对以上影响因素提出了相应的对策。首先医院领导重视,提高医师对病案首页的书写质量以及ICD-10的普及和学习,提高编码员的素质水平,正确选择肿瘤的主要诊断,从而保证肿瘤疾病分类编码的准确性、完整性。
The aim of this paper was to analyze the influential factors of the tumor coding accuracy.The inappropriate diagnoses writing of doctors,the short of professional coder,the inconsistent information between pathological diagnosis and primary diagnosis,and the inaccurate primary diagnosis of tumor,which were the main factors that influenced the accuracy of the tumor coding.We propose some measures bases on above influential factors.Firstly,the leaders should pay attention to the tumor coding,and strengthen training about related knowledge of ICD-10 among doctors to improve the diagnosis accuracy and writing standard of doctors.Besides,the coders should improve the professional quality to select the primary diagnosis of tumor,so as to ensure the accuracy and integrality of tumor classification and coding.
作者
龚菊
Gong Ju(Statinstics Office of Tianyou Hospital Affiliated to Wuhan University of Science and Technology, Wuhan 430064, Hubei Province, Chin)
出处
《中国病案》
2016年第10期32-34,共3页
Chinese Medical Record
