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目的探讨死亡病例网络报告中存在的主要问题并制定对策。方法回顾与分析死亡病例网络报告的填写结果,查找报告中存在问题。结果发现临床医师对死亡原因和根本死因概念不清,未按基本要求填写死亡医学证明书,导致诊断不规范;编码人员忽略修饰规则和重要注释,使主要疾病诊断选择错误。结论应加强对医师和网络上报人员的培训,改进死亡病例网络报告填写中的不足,正确选择主要诊断及编码。
Objective To explore the main problems in the network of death cases and to develop countermeasures. Methods To review and analyze the results of online reporting of death cases and to find out the problems in the report. The results showed that clinicians were not clear about the cause of death and the underlying cause of death and did not fill in the death certificate as required by the basic requirements, leading to non-standard diagnosis. The coder neglected the modification rules and important annotations to make wrong diagnosis of major diseases. Conclusion The training of physicians and network escalation personnel should be strengthened, the deficiencies in filling the network report of death cases should be improved and the main diagnosis and coding should be correctly selected.