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采用按诊断检索和手术方式检索的方法检索病案首页信息数据库,探讨具有Q51和Q52编码的妇科生殖器畸形病案的主要诊断选择问题以及漏编码问题。利用检索数据库的方式可发现漏编、漏检以及主要诊断选择错误的问题。采用这种方法可以迅速找到编码错误的病案,提高工作效率以及数据检索的完整性和准确性,但是也会遗漏部分漏编码病案。明确疾病的主要诊断选择原则,提供自查自检漏编码问题的方法,可以提高病案编码的正确性,提高病案检索的查准率和查全率,为临床研究提供更全面、准确的数据基础。
The first page of medical record information database was retrieved by means of diagnostic search and surgical retrieval, and the main diagnostic options and the problem of missed coding of gynecological genital malformations with Q51 and Q52 codes were explored. The use of search database can be found in the leak code, missed inspection and the main diagnosis of the wrong choice. Using this method can quickly find the wrong coding case, improve work efficiency and data retrieval of the completeness and accuracy, but also omission of some missing coded medical records. To clarify the principle of diagnosis and selection of diseases and to provide a self-examination and self-checking method of leakage coding can improve the accuracy of medical record coding and improve the accuracy and recall of medical record retrieval so as to provide a more comprehensive and accurate data foundation for clinical research .