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目的进一步研究并分析病案书写质量对医院疾病编码正确性的影响。方法对2014年7月-2015年10月因病案书写质量问题而导致患者疾病编码错误的200份案例进行回顾研究,并针对病案书写质量缺陷问题提出整改意见。结果造成疾病编码有失正确性的病案书写质量原因主要有,病案首页疾病诊断名称不统一、参差不齐,患者手术记录、医嘱内容缺失或不准确,体检检查书写内容同患者病史内容不一,未填写根本死亡原因或是对死亡原因选择错误,患者特殊检查操作填写不完整以及辅检报告单未归入档案以及书写人员职称不同等,上述主要病案书写质量问题不仅导致患者疾病编码的错误,而且严重影响了患者的手术操作与诊治,为患者带来了极大的威胁。结论患者病案的书写质量是决定其疾病编码正确性的根本,对患者的治疗有着极为重要的影响,而疾病编码的正确性则又反映着病案书写的质量好坏。二者关系密切,应予重视。
Objective To further study and analyze the impact of medical record quality on the correctness of hospital disease codes. Methods A retrospective study was conducted on 200 cases of patients’ disease coding errors caused by the quality of medical record writing from July 2014 to October 2015 and suggestions for rectification were put forward according to the quality defects of medical records. As a result, the quality of the medical record cases that resulted in the incorrect correctness of the disease codes were mainly due to the inconsistency between the names of the medical records and the patient records, the missing or inaccurate contents of the doctor’s orders, Failure to fill in the root causes of death or the reasons for the death of the wrong choice, the patient does not complete the special inspection operations and the supplementary report is not included in the file and writing staff titles are different, the major medical record quality problems not only led to the patient’s disease coding error, But also seriously affected the patient’s operation and diagnosis and treatment, bringing great threats to patients. Conclusion The writing quality of a patient’s medical record is the basis for determining the correctness of the disease’s coding. It has a very important influence on the patient’s treatment. The correctness of the disease’s coding reflects the quality of the medical record’s writing. The two are closely related and should be given attention.