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列举主要诊断与手术操作不相符合病例编码工作中的实际案例,查阅原始病案,以讨论的形式分析其中存在的编码问题,包括主要诊断选择错误、主要诊断编码错误及手术/操作编码错误等。错误产生的原因主要有编码员编码知识不足、临床知识缺陷以及阅读病历能力不足,临床医师病案首页书写不规范,医院需加强精细化管理等。科学、准确的疾病编码有赖于临床医师、编码人员及医院管理者等的共同努力。
The main cases of diagnosis and surgery do not match the actual cases of case coding work, refer to the original case, to discuss the form of analysis of the coding problems that exist, including the main diagnosis of choice error, the main diagnosis of coding errors and surgical / operational coding errors. The main reasons for the error coder coding lack of knowledge, clinical knowledge deficiencies and reading medical records capacity is not enough, the first page of the doctor’s medical record is not standardized, the hospital needs to strengthen the fine management. Scientific and accurate disease coding depends on the joint efforts of clinicians, coders and hospital administrators.