做好疾病诊断名称与疾病分类编码对照提升病案首页质量
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摘要
疾病分类是确定卫生趋势和统计数据的基础,而国际疾病分类作为报告疾病和健康状况的国际标准,是国际间交流的桥梁,然而在应用过程中医师的疾病诊断名称与疾病分类编码库的对照往往存在诸多问题。因此通过收集整理、现状分析、规范诊断名称、标注关键词、首字母及相关汉字检索的流程改造方法,强化了疾病诊断名称与疾病分类编码库之间的对照,方便了临床医师快速便捷地找到疾病诊断名称及相对应的疾病分类编码,优化了疾病诊断的书写与编码工作流程,规范了医师书写疾病诊断的习惯,使得疾病分类编码更加准确。同时减轻编码员的工作负担,提高编码效率,从而提升了病案的质量,更好地服务了临床,更大地发挥病案的价值。
Disease classification is the basis for determining health trends and statistics, and international disease classification as an international standard for reporting disease and health status is a bridge for international exchanges. However, in the application process, the doctor's disease diagnosis name and disease classification code library are compared. There are often many problems. Therefore, through the process of collecting and sorting,analyzing the status quo, standardizing the name of the diagnosis, labeling keywords, initial letters and related Chinese character retrieval process, the contrast between the disease diagnosis name and the disease classification code library is strengthened, which is convenient for clinicians to find quickly and conveniently. The name of the disease diagnosis and the corresponding disease classification code optimize the writing and coding workflow of the disease diagnosis, standardize the habit of doctors to write disease diagnosis, and make the disease classification code more accurate. At the same time, the workload of the coder is reduced, the coding efficiency is improved, the quality of the medical record is improved, the clinical service is better served, and the value of the medical record is exerted more.
Disease classification is the basis for determining health trends and statistics, and international disease classification as an international standard for reporting disease and health status is a bridge for international exchanges. However, in the application process, the doctor's disease diagnosis name and disease classification code library are compared. There are often many problems. Therefore, through the process of collecting and sorting,analyzing the status quo, standardizing the name of the diagnosis, labeling keywords, initial letters and related Chinese character retrieval process, the contrast between the disease diagnosis name and the disease classification code library is strengthened, which is convenient for clinicians to find quickly and conveniently. The name of the disease diagnosis and the corresponding disease classification code optimize the writing and coding workflow of the disease diagnosis, standardize the habit of doctors to write disease diagnosis, and make the disease classification code more accurate. At the same time, the workload of the coder is reduced, the coding efficiency is improved, the quality of the medical record is improved, the clinical service is better served, and the value of the medical record is exerted more.
引文
[1]刘爱民,主编.病案信息学[M].第二版.北京:人民卫生出版社,2014:132-135.
[2]董景五,主译.疾病和有关健康问题的国际统计分类:第十次修订本,第二卷[M].第二版.北京:人民卫生出版社,2008:8.
[3]赵红梅,邓世渊,赵越,等.临床诊断书写规范化方法研究[J].中国医院管理,2014,34(10):26-28.
[4]赵杰,李想,梁健,等.脑膜瘤形态学编码分析[J].中国病案,2017,18(3):28-30.
[5]楼伟民.浅谈ICD-10编码员持证上岗的培训教育[J].中国病案,2005,6(11):43-44.
[6]裴珮,李丽华,赵桐,等.掌握医学知识对编码员准确编码的影响[J].中国病案,2018,19(5):30-32.
[7]张萌,廖爱民,刘海民,等.ICD-11与ICD-10分类体系的对比研究[J].中国病案,2016,17(6):21-24.
[2]董景五,主译.疾病和有关健康问题的国际统计分类:第十次修订本,第二卷[M].第二版.北京:人民卫生出版社,2008:8.
[3]赵红梅,邓世渊,赵越,等.临床诊断书写规范化方法研究[J].中国医院管理,2014,34(10):26-28.
[4]赵杰,李想,梁健,等.脑膜瘤形态学编码分析[J].中国病案,2017,18(3):28-30.
[5]楼伟民.浅谈ICD-10编码员持证上岗的培训教育[J].中国病案,2005,6(11):43-44.
[6]裴珮,李丽华,赵桐,等.掌握医学知识对编码员准确编码的影响[J].中国病案,2018,19(5):30-32.
[7]张萌,廖爱民,刘海民,等.ICD-11与ICD-10分类体系的对比研究[J].中国病案,2016,17(6):21-24.