Problems Of Main Selection In Diagnosis And Coding Of Clinical Diseases And Solutions

With the improvement of living standards, people have chosen to pay more attention to health care. This development puts forward higher requirements for hospital management and future development. As a result of the development, the question how to improve the level of medical service, provide better care for patients, and improve their own shortcomings has become a top priority. With the rapid development of medical technologies, new technologies and high-tech equipments have been widely introduced in clinical treatments. The development requires correct medical record coding.ICD (International Classification of Diseases) is a standard of statistical classifications of diseases,injury and causes of death. As the core technology of medical record information management, ICD coding has been the main aim which is needed to be explored by experts. At the same time, DRGs (Diagnosis Related Groups) put forward higher requirements for the selection of primary diagnosis of the medical record and the accuracy of disease coding. Due to the selection errors of the main diagnosis and disease coding, many hospitals had notonly economic losses but also a certain impact on patient treatments.The paper examined the error data on the selection of the main diagnosis and disease coding from eight clinical departments. It was found that the error data made by the trained and untrained clinicians and coders was totally different. The errors made by trained ones were much lower compared with untrained. The errors found mainly in (1) the diagnostic errors which were mainly due to unclear diagnosis description; (2) disease coding errors that were because of unclear coding rules, the physiological mechanism of the disease.It was found that problems in diagnostic parameter selection and coding of clinical major diseases were caused due to poor disease coding, the lack of well-trained doctors and coders, inaccurate and even incorrect medical records. We suggested that (1) clinicians should frequently communicate with coders on disease coding; (2) clinical training of doctors about ICD should be strengthen; (3) coders and doctors should pay more serious attentions to correct disease coding.