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目的探讨妇产科住院病案首页的主要诊断和主要手术不一致的原因,研究如何合理选择妇产科病案首页的主要诊断,使其与主要手术操作相一致。方法提取2014年妇产科15 652份出院病案,其中11 588份含有各种妇产科手术操作,了解主要诊断与主要手术操作的填写情况。结果 11 588份住院病案的主要诊断和主要手术操作符合率77.5%,8981份主要诊断与主要手术相匹配,1043份属于部分不一致,1564份属于完全不一致。1043份部分不符合的病例中,妇科所占比例82.55%;产科仅占比17.45%。而1564份完全不符合的病例中,产科所占比例83.63%;妇科占比16.37%。结论主要诊断选择需要根据患者疾病的临床诊疗过程和主要诊断选择原则等多方面因素综合判断,主要手术操作应与主要诊断相对应。
Objective To explore the main reasons for the inconsistency between the main diagnosis and the main operation in the obstetrics and gynecology inpatients, and to study how to select the main diagnosis of obstetrics and gynecology on the first page so that it is consistent with the main operation. Methods A total of 15 652 cases of discharge from obstetrics and gynecology in 2014 were extracted. Among them, 11 588 cases contained various obstetrics and gynecology operations and their main diagnoses and major surgical operations were completed. Results The main diagnosis and major surgical procedures of 11 588 inpatient cases coincided with 77.5%. 8 981 major diagnoses matched major operations, 1043 were partially inconsistent and 1564 were completely inconsistent. Of the 1043 partially non-compliant cases, the proportion of gynecology was 82.55%; obstetric accounted for only 17.45%. Among 1564 totally nonconforming cases, obstetric accounted for 83.63% and gynecology accounted for 16.37%. Conclusions The main diagnostic options need to be comprehensively judged according to various factors such as the clinical diagnosis and treatment process of patients’ diseases and the principle of major diagnosis. The main surgical operations should correspond to the main diagnosis.