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病案首页主要诊断的选择

病案首页主要诊断的选择

焦建军

    [摘要]介绍并分析了病案首页主要诊断数据采集现状,阐述了正确选择和填写病案首页主要诊断的重要性。同时还介绍了如何正确选择主要诊断,明确了主要诊断的定义,主要诊断选择的原则。此外,还介绍了一些在正确选择主要诊断方面的一些体会。这些内容旨在针对目前主要诊断的状况及存在的问题进行分析,以帮助医务人员在工作中正确填写主要诊断。

病案首页;  主要诊断;  诊断相关组预定额付费;  医院评价

Selection of principal diagnosis on the front page of medical recordsJIAO Jian-junFirst Hospital of Beijing University ,Beijing 100034 ,China.

     [Abstract]  The present situation of data acquisition of principal diagnosis on front page were introduced and analyzed, the importance of selection and filling out the principal diagnosis on from page were expounded. Meanwhile, how to select the principal diagnosis correctly, clear and definite the definition of Principal Diagnosis, rule of selection of principal diagnosis were also introduced. Besides,some experience on how to select the principal diagnosis were presented. All of these, that analyzing the present situation and the problems of principal diagnosis, in order to assisting medical staff to select principal diagnosis correctly.

Front page;   Principal diagnosis;  DRGs-PPS33;  Assessment of hospital

10. 3760/cma. j. issn. 1000-6672. 2011.11. 008

北京大学医学部“985工程”二期建设项目(985205989)

100034 北京大学第一医院

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