摘要：
目的 对内科住院死亡病案首页中丰要诊断及其他诊断填写存在的问题进行分析,寻求正确书写内科死亡病案首页诊断的有效措施,以提高死亡病案首页诊断的书写质量.方法 回顾性调查并分析某三甲医院2016年1月-12月内科住院死亡病案119份,病案质控医师及编码员对临床医师填报后的病案首页诊断存在的问题进行分析,找出诊断中的书写缺陷.结果 119份内科死亡病案首页中,主要诊断及其他诊断存在问题率为48.7％,并存在于每个内科科室,其中呼吸内科、抢救监护和心内科占比较大,主要问题为主要诊断选择错误,其他诊断漏诊,疾病诊断不规范.结论 针对内科死亡病案首页诊断填报存在的问题,对临床医师开展专题培训与研讨,以及临床医师与编码员、质控医师及时沟通,能够有效提高内科死亡病案首页诊断书写正确率.%Objectives To conduct analysis on the problems existing in the filling of principle diagnosis and other diagnosis in the front pages of death medical records in internal medicine system,seek the effective measures to make correct filling of front pages of death medical records in internal medicine department,so as to improve the filling quality of diagnosis in the front pages of death medical records.Methods 119 cases of death medical records in internal medicine department of a Three A and Tertiary Hospital from January 2016 to December were etrospective investigated.The medical records quality control coders and clinical physicians made analysis on the problems existing in the diagnosis of front pages,and found out the filling defects in thegm.Results In the front pages of 119 cases of death medical records in internal medicine department,the main diagnostic and other problems rate were 48.7％,and existing in every internal medicine departments,in which respiratory medicine department,rescue monitoring and cardiology departments took relative large proportion,with the main problems included selection of diagnostic errors,lack of other diagnosis,and not standard disease diagnosis.Conclusions Aiming at the problems existing in the filling of diagnosis in front pages of death medical records in internal medicine department,we should conduct professional training and investigations on clinicians,and the clinicians should make communication with disease coders and quality control doctors timely,in order to improve the filling accuracy of front pages of death medical records in internal medicine department effectively.
