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病案首页疾病诊断和手术,操作名称填写错误,会导致疾病和手术、操作分类编码错误,国家卫生信息库汇总形成的数据就不会准确。其原因之一是国际疾病分类主要针对病案管理人员培训学习和应用,忽视了对医师的培训,导致医师群体此类知识缺如。应加强临床医师正确书写疾病诊断与疾病分类原则的学习,改进由于诊断书写错误导致的统计数据失真。
Disease diagnosis and surgery, the name of the operation to fill in the wrong, will lead to disease and surgery, classification of operational classification error, the national health information pool formed by the data will not be accurate. One of the reasons is that the international classification of diseases mainly focuses on the study, training and application of case management personnel, neglects the training of physicians and leads to such lack of knowledge of the physician group. Clinicians should be encouraged to correctly write the principles of disease diagnosis and classification of diseases to learn and improve statistical errors caused by misdirected medical records.