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通过临床实际案例分析提出编码人员认真阅读手术记录对于编码正确性的影响。为保证病案首页疾病编码的准确性和严谨性,编码人员要在日常工作中养成精读手术记录的习惯,抓住手术记录内容影响疾病诊断编码的关键点;同时增强编码员相关临床疾病专业知识的学习和编码工作经验的积累;根据国际疾病分类原则正确使用ICD合并编码,提高编码部位的准确性。同时不断加强临床医师国际疾病分类知识的了解,不断加强临床医师病历书写规范和病案首页填报的培训。
Through the clinical case analysis, we proposed that the coder carefully read the influence of the operation record on the coding correctness. In order to ensure the accuracy and rigor of the disease coding on the first page of the medical records, the coders should cultivate the habit of intensive operation records in their daily work, grasp the key points of the surgical records affecting the disease diagnosis codes, and enhance the professional knowledge of coder-related clinical diseases Learning and coding work experience accumulation; according to the international classification of diseases correctly use the ICD merger coding, improve the accuracy of the coding site. At the same time, we should continue to enhance the knowledge of clinicians about the classification of international diseases and continue to strengthen the training of clinicians in writing medical records and on the first page of medical records.