摘要
目的分析某三甲医院康复医学科病案主要诊断填写存在缺陷,探讨该学科主要诊断选择,为提高该学科主要诊断选择正确率提供参考。方法从某院病案信息系统中导出2018年1月1日-2018年12月31日期间出院的847份康复医学科病案主要诊断填写情况,运用Microsoft Office Excel 2010进行归纳、整理及运算,回顾性分析康复医学科主要诊断缺陷情况。结果847份康复医学科病案主要诊断缺陷共计231份,占总人数的27.27%,其中责任主体临床医师主要问题有:错误选择后遗症为主要诊断98份,占总缺陷病案的42.42%、滥用术后诊断71份,占总人数的30.74%、主要诊断名称不规范37份,占总缺陷病案的16.02%;责任主体编码员主要问题有:对自身临床知识、ICD-10编码原则和主要诊断选择知识掌握不足25份,占总人数的10.82%。结论每个学科的主要诊断选择均有具有其特异性,临床医师应加强住院病案首页尤其是主要诊断填写的培训,规范考核制度及其诊断名称书写;编码员应加强临床及编码知识的贮备,不断提升国际疾病分类及主要诊断选择知识,从而促进康复医学科主要诊断正确率的提高。
Objective To analyze the defects in the main diagnosis filling in the medical records of rehabilitation medicine department in a third-grade hospital,and to explore the main diagnosis selection of this discipline,so as to provide reference for improving the correct rate of the main diagnosis selection of this discipline.Methods From the medical record information system of a hospital from January 1,2018 to December 31,2018,847 medical records of rehabilitation medicine department were derived from the main diagnosis filling information.Microsoft Office Excel 2010 was used to summarize,organize and calculate the main diagnosis defects of rehabilitation medicine department.Results 847 rehabilitation medicine medical record defects a total of 231 primary diagnosis,accounting for 27.27%of the total,clinicians main problems are:the main responsibility of the wrong choice legacy as the main diagnostic 98,accounting for 42.42%of the total defects in medical record,abuse of postoperative diagnosis of 71,accounting for 30.74%of the total,the main diagnosis name is not standard 37,accounting for 16.02%of the total defects in medical record;The main problems of the coders of the subject of responsibility were as follows:they had less than 25 copies of their own clinical knowledge,ICD-10 coding principles and main diagnostic selection knowledge,accounting for 10.82%of the total number.Conclusion The main diagnostic selection of each discipline has its own specificity.Clinicians should strengthen the training of the first page,especially the main diagnosis filling,standardize the examination system and the writing of the diagnosis name.Coders should strengthen the clinical and coding knowledge,and constantly improve the knowledge of international classification of diseases and the main diagnosis selection,so as to promote the improvement of the main diagnostic accuracy of rehabilitation medicine.
作者
韦芳
吴韫宏
滕燕飞
梁世鹏
雷粤伶
黄丽萍
彭希
Wei Fang;Wu Yunhong;Teng Yanfei;Liang Shipeng;Lei Yueling;Huang Liping;Peng Xi(The Second Affiliated Hospital of Guangxi Medical University,Nanning 530000,Guangxi Zhuang Autonomous Region,China;不详)
出处
《中国病案》
2021年第8期3-5,共3页
Chinese Medical Record
关键词
康复医学科
病案
主要诊断
Rehabilitation medicine
Medical record
Main diagnosis
