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目的通过对2例危重病例的主次诊断选择与疾病分类编码进行分析,找出问题,提高疾病主次诊断与编码的选择正确性。方法根据国际疾病分类的主要诊断选择原则与编码的规则,对2例危重病例的主要诊断与编码选择进行检查。结果 2例危重病例的主要诊断与编码选择均错误。结论加强临床医师对于疾病主要诊断选择的定期培训,加强编码员专业知识及临床知识学习,增强工作责任心,提高编码水平,力争使病案编码正确率达到三级医院等级评审要求90%以上。
OBJECTIVE: To analyze the selection of primary and secondary diagnosis and classification of disease in two critical cases to identify the problems and improve the correctness of primary and secondary diagnosis and coding of diseases. Methods According to the main principles of diagnosis and selection of international classification of diseases and coding rules, two cases of critically ill patients were diagnosed and their coding options were examined. Results The diagnosis and coding of two critical cases were all wrong. Conclusions The clinicians should strengthen the regular training on the main diagnosis options of the disease, strengthen the coder’s professional knowledge and clinical knowledge learning, enhance their sense of responsibility and improve the coding level so that the correct rate of case coding reaches 90% of the level 3 hospital grade assessment requirements.