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目的通过对分娩伴产后出血病例的分析,明确分娩伴产后出血病例主要诊断的选择,以及准确编码。方法通过某院病案首页信息管理系统检索2012年-2016年产后出血病例,分析主要诊断选择情况以及编码情况,统计错误率。结果 2012年-2016年出院诊断中有产后出血的897例,其中诊断为产后大出血的228例,产后出血患者主要诊断选择错误率12.93%,其中以产后大出血为主要诊断病例占错误率的92.24%。结论以产后大出血为主要诊断病例应以导致产后出血的原因作为主要诊断,并应注意合并编码的使用。医务部门对临床医师的病案首页填报进行培训,编码人员加强与临床医师的充分沟通,共同确保编码的正确性,协同完成病案首页上报工作。
Objective Through the analysis of cases of childbirth with postpartum hemorrhage, clear the choice of the main diagnosis of childbirth with postpartum hemorrhage, and accurate coding. Methods A case of postpartum hemorrhage from 2012 to 2016 was searched through the home page information management system of a hospital medical record. The main diagnostic options, coding status and statistical error rate were analyzed. Results 897 cases of postpartum hemorrhage were diagnosed during discharge from 2012 to 2016, of which 228 cases were diagnosed as postpartum hemorrhage. The main diagnostic error rate was 12.93% in postpartum hemorrhage. Among them, 92.24% . Conclusion The main diagnosis of postpartum hemorrhage should be the main cause of postpartum hemorrhage as the main diagnosis, and should pay attention to the use of combined coding. Medical departments of the clinicians fill out the first page of medical records for training, the code staff to strengthen the full communication with clinicians, to ensure the correctness of the code, collaboratively complete the first case of medical records.