摘要
对国内以提高国际疾病分类(ICD)编码质量与效率为主题的研究论文进行统计、分析与总结。目前,关注ICD质量与效率的研究成果不多,其研究的内容大致可分为ICD编码质量与效率影响因素的分析及提高ICD编码质量与效率的途径两大部分。影响因素包括编码人员的自身因素、临床医师因素及其他因素三大类,而解决这些问题可通过提高编码人员综合素质、提高临床医师病历书写质量及对其ICD知识的了解、建立ICD字典库、改变编码的模式及应用现代化技术等途径。最后,文章指出现有研究的不足,并提出"学科编码员"的观点。"学科编码员"基于学科服务的ICD编码模式,是提高编码人员的责任心与业务能力、加强编码人员与临床医师沟通的有效途径;自动化编码、疾病与手术命名标准化亦是值得进一步探讨的问题。
This paper conducted a statistical analysis and summary on the theme of improving the quality and efficiency of ICD coding which in the domestic research papers.At present,the researches on improving the quality and efficiency of ICD coding are not much.The content of the research can be divided into two parts,which are the analysis of the influence factors of the quality and efficiency of ICD coding and the way to improve the quality and efficiency of ICD coding.The influence factors include the factors of coder,the factors of clinician and other factors.And the ways to solve these problems include improving the overall qualities of coders,the quality of medical recording and the ICD knowledge of clinicians,establishing the ICD database,changing the model of coding and using the modern technologies and so on.This paper put forward the shortcomings of existing research at last,and raised the point of ＂Subject coder＂.It was an ICD coding model which base on the subject service.It was an effective way to improve the responsibility and professional ability of coders and to strengthen the communication between the coders and the clinicians.Automatic coding,standardization of nomenclature of diseases and surgery still needed further discussion.
作者
邓添薪
廖宁
张帆
满丽芳
朱芳芳
王君璇
李浪
Deng Tianxin Liao Ning Zhang Fan Man Lifang Zhu Fangfang Wang Junxuan Li Lang
出处
《中国病案》
2017年第1期28-32,共5页
Chinese Medical Record
基金
广西医药卫生自筹经费计划课题(Z2016727)
关键词
ICD
编码
质量
效率
ICD
Coding
Quality
Efficiency
