摘要分析了当前病案首页诊断编码工作发展情况及存在的主要问题,提出现阶段迫切需要统一编码标准、正确选择编码技术、科学组织编码工作.在此基础上,对病案首页诊断编码工作的发展趋势及策略进行了探讨,提出病案首页作为重要的数据源将持续存在且越来越重要.随着ICD-11的发布和医学名词的规范化建设,诊断编码技术将快速发展,诊断编码技术的复杂性及存在大量常规编码工作量这两个因素决定了专业编码员将继续发挥关键作用.医院应重视并提高病案首页质量,加强医院诊断编码工作建设.

abstractsThis paper analyzed the development and main problems found in medical diagnosis coding of medical record homepage. It proposed that it is imperative to unify the coding criteria, to correctly identify coding techniques, and to organize the coding work scientifically. On that basis, the paper discussed the development trend and strategy of medical diagnosis coding work for medical record homepage. As an important data source, the homepage of medical records will continue to exist and play a more important role. With the release of ICD-11 and the standardization of medical terms, the diagnosis coding technology will progress very rapidly. Such factors as the technical complexity and the sizable workload of routine coding, have decided fulltime coders will continue their key role as before. Hospitals are recommended to emphasize the quality of medical record homepage, and their diagnosis coding work.