【摘要】 目的 分析某市47家医院病案首页主要诊断编码的缺陷，并针对发现的问题提出解决方案。方法 某省病历质控中心组织病历督导专家，对某市47家医院各随机抽取20份病历，共940份，检查病案首页主要诊断及编码的准确性。结果 通过督导检查，主要诊断选择医生填写正确率为80.32%,编码正确率为75.53%。错误类型主要集中在诊断选择错误、编码过于笼统或粗犷、肿瘤病历诊断选择不准确、患者临终状态或症状作为主诊等方面。结论 通过加强临床医师和编码员的病案首页诊断编码培训，并建立有效的管理体系和考评机制，利用信息化手段，完善病案首页质量控制系统等方式，可以提高诊断编码的准确性。更多还原

【Abstract】 Objective Analyzes the defects of the main diagnostic codes on the homepage of medical records of 47 hospitals in a city, and proposes solutions for the problems found.Methods The provincial medical record quality control center organized medical record supervision experts to randomly select 20 medical records from 47 hospitals in a city, a total of 940 copies, to check the accuracy of the main diagnosis and coding on the first page of the medical records. Results Through the supervision and inspection, the correct rate of filling in the main diagnosis and selecting doctors was 80.32%, and the correct rate of coding was 75.53%. The main diagnostic coding errors are mainly concentrated in the wrong choice of diagnosis, rough coding, inaccurate choice of diagnosis in tumor medical records, and the patient’s terminal state or symptoms as the main diagnosis. Conclusion By strengthening the diagnostic coding training of clinicians and coders on the homepage of medical records, establishing an effective management system and evaluation mechanism, and using information technology to improve the quality control system, can improve the accuracy of diagnostic coding.更多还原