影响病案统计资料准确性的因素及管理对策.docVIP

影响病案统计资料准确性的因素及管理对策 孙雪梅(邳州市中医院病案室江苏邳州221300) 【中图分类号】R197.32【文献标识码】A【文章编号】1672-5085 ( 2012 )4-0411-02 【摘要】目的探讨影响病案统计资料的准确性因素及管理方法。有利于服务于 临床、医疗、教学、科研、保险、咨询、法律等。国际疾病分类是以编码的形式 对医院所收治病人的疾病按编码分类的原则给予分类。因此，疾病编码的正确与 否直接影响医疗质量的评估和医疗资源的利用，影响着医疗统计报表的准确性， 也影响医教研的检索利用。笔者从事病案工作多年，对常见的影响病案统计资料 准确性的因素有了一定的体会。病案是病人在医院诊断、治疗全过程的原始记录， 它包含有首页病程记录、检查与检验结果、医嘱、手术、护理记录等。它服务于 临床、医疗、教学、科研、保险、咨询、法律等各个领域。 【关键词】病案统计资料准确性管理对策 【Abstract】 Objective To investigate the effect of medical record the accuracy of statistical data and management method. For services in clinical, medical, teaching, scientific research, insurance, consulting, legal and other. The international classification of diseases is encoded in the form of our hospital from the patients disease coding according to the classification principle of classification. Therefore, the disease coding is correct or not directly affect the quality of medical evaluation and utilization of medical resources, affects the accuracy of medical statistics, also affect the retrieval and utilization of medical teaching and research. The author is engaged in the work for many years, the common affect the accuracy of statistics on cases factors have certain experience. Medical records of patients in the hospital diagnosis, treatment of the entire process of the original recording, which includes home course records, check and test results, medication, operation, nursing records. It serves the clinical, medical, teaching, scientific research, insurance, consulting, legal and other fields. 【Key words】 veracity of medical record statistic data management countermeasure 国际病案疾病分类管理；是以编码的形式对医院所收治病人的疾病按编 码分类的原则给予分类。因此，疾病编码的正确与否直接影响医疗质量的评估和 医疗资源的利用，影响着医疗统计报表的准确性，也影响医教研的检索利用。笔 者从事病案工作多年，对常见的影响病案统计资料准确性的因素体会如下。 1病案编码 1.1掌握好疾病的病案编码，编码人员必须认真阅读病历。编码人员不 认真阅读病历，只凭首页诊断名称编码，往往造成编码不准确，如阑尾炎是急性、 慢性、化脓性、是否穿孔伴腹膜炎等。疝气是直疝、斜疝、股疝，脐疝，是否嵌 顿，能否还纳，是否伴有梗阻，编码都不相同。 1.2对病历内容分析后才能进行正确编码，如：肠梗阻疾病诊断，不阅 读病历编码为K56.7,但实际上病人是手术后造成的肠梗阻应编码到K91.3。尿道 狭窄N35.9,阅读病历后知道是前列腺摘除术后并发尿道狭窄，正确编码为N99.1。 1.3提高专业技术