摘要
通过对黑龙江省某三级甲等医院规范病历书写及疾病编码后的2016年病历与规范前2015年病历对比分析,同时按照DRGs理论的要求,分析病历书写及疾病诊断、手术编码存在的问题,深入分析影响病历书写及编码的影响因素,从而规范病历书写及编码质量,为DRGs预付费制度的顺利实施奠定坚实基础。
Through the comparison and analysis of the medical records between 2016 standard writing an disease coding medical records and 2015 medical records,and according to the requirements of DRGs theory,the problems of medical record writing,disease diagnosis and operative coding are analyzed,and the factors that influence the writing and coding of medical records are also analyzed,so as to standardize the quality of medical record writing and coding,to promote the quality of the coding,and to lay a solid foundation for the DRGs prepayment system.
作者
曹蕊
蔡秀芝
张宇
王大鹏
李会玲
CAO Rui;CAI Xiu-zhi;ZHANG Yu(The First Affiliated Hospital of Harbin Medical University,Harbin,Heilongjiang,150001,China)
出处
《中国医院管理》
北大核心
2018年第7期39-41,共3页
Chinese Hospital Management
基金
黑龙江省卫生计生委科研课题项目(2014-283)
