【摘要】 目的了解医生选择主要诊断的准确性与患者病情有无关系,分析造成错误的原因,探讨提高主要诊断准确性的有效措施。方法回顾性调查1000份新版首页,按主要诊断选择原则进行核查,分别统计主要诊断所对应的入院病情、有无转科、各个病例分型的主要诊断选择正误的情况,作统计学分析比较。结果主要诊断选择错误率为7.70%;有转科病例主要诊断选择错误率高于无转科者,差异有显著性(χ2=14.04,P<0.01);病例分型C+D型的主要诊断选择错误率高于A+B型,差异有统计学意义(χ2=26.89,P<0.01)。结论主要诊断错误的原因主要是由于临床医师缺乏国际疾病分类知识,且对选择主要诊断的重要性认识不足。改进措施关键是加强继续教育,让医师充实有关ICD的知识,并自觉重视正确选择主要诊断;提高编码员的业务素质。更多还原

【Abstract】 Objective As the principal diagnosis of the front page of the new medical records is the basis of the ICD coding and statistics and whether it is correctly filled out means a lot, the thesis aimed to check whether the correctness of doctors selecting principal diagnosis is related to the patients state of illness, analyse the causes for the mistakes and discuss effective measures to improve the correctness of the principal diagnosis. Methods Retrospective investigations and examinations of 1000 medical records with new editions of the front page (among which there were more than one discharge diagnosis) in a certain large scale comprehensive hospital according to the principle of the selection of principal diagnosis were carried out. Meanwhile, state of illness of admission corresponding to principal diagnosis, whether or not the patient changed departments, the correctness of the selection of principal diagnosis of all case classifications were analyzed respectively and processed statistically. Results 7.70% of the selections of principal diagnosis were incorrect. Those who changed their departments had the higher error rate of the selection of principal diagnosis than those who did not, which had significant difference (χ2 =14.04,P<0.01). Case Classification Type C+D had the higher error rate of the selection of principal diagnosis than Case Classification Type A + B, which were statistic significant (χ2 =26.89,P<0.01). Conclusion The major causes for the incorrectness of the selection of principal diagnosis lie in clinicians lack of knowledge of the international classification of diseases (ICD) and insufficient understanding of importance of selecting principal diagnosis. In order to ensure the principal diagnosis of the front page is correct, the key is to strengthen further education, letting clinicians enrich their knowledge of ICD and consciously attach great importance to the correctness of selecting principal diagnosis and whats more, improving the professional skills and working responsibilities of the coders.更多还原