【摘要】 目的在对出院病历首页进行ICD-10疾病编码的过程中,不时会发现出院诊断的书写、主要诊断的选择、临床疾病诊断与ICD-10编码中对应的疾病诊断方面有一些出入,希望能就典型例子的分析,减少出现的错误,做好ICD-10疾病编码的工作。方法以主要诊断的选择规则结合ICD-10疾病编码规则及临床医学知识对有疑问的出院诊断通过审阅整本病历研究判断出院诊断的正确性。结果发现了不同类型的存在错误或缺陷的出院诊断。结论临床医生需加强出院诊断的相关技能训练,编码员需不断提高ICD-10编码技能及拓宽临床知识面,临床疾病诊断与对应的ICD-10编码中的疾病诊断最好能统一。更多还原

【Abstract】 Objective in the process of ICD-10 coding on the first page of medical records,the writing of the discharge diagnosis,the selection of the main diagnosis and the diagnosis of clinical disease were different with ICD-10 coding.We hoped to reduce the errors by analyzing the typical samples.Methods According to the rules of ICD-10 coding and the clinical knowledge,we have judged the accuracy of discharge diagnosis by checking the whole medical records.Results Parts of the discharge diagnosis were not scientific and standard.Conclusion Clinical doctors should enhance the skill training on discharge diagnosis,coders should enhance the skill training on ICD-10 coding and the clinical knowledge,the diagnosis of clinical disease should be unified with ICD-10 coding.更多还原