摘要
目的:医生从对照表中选择常用诊断名称,实现带有标准编码的疾病诊断名称惯穿病人医疗全过程。方法:医生手工书写疾病诊断名称后,病案统计人员对照编码,将生成的对照表再提供给医生与统计人员使用,形成一个良性循环。结果:通过测试,发现经过一段时间的循环累积,确实可以生成常用诊断与标准ICD-10的对照表。结论:通过对生成的对照表分析以及和临床、病案统计部门工作人员讨论,得到了对照表积累到一定程度后,确实能满足临床医生书写诊断的需要,能方便病案、统计等部门的工作。这种在医疗过程中实现疾病自动编码的方案值得深入研究和推广。
Objective：The doctor used diagnosis name from the table, the disease diagnosis with standard code name used to wear the whole process of patient care. Methods：Doctors hand writing the name of the disease, the statistical personnel control code, wilt generate the table to provide doctors and statisticians use, forming a virtuous circle. Results：Through the test, found that after a period of time the cumulative,table can indeed produce common diagnosis and standard ICD-10. Conclusion： Based on analysis of the control table of clinical, medical records and statistics department staff, has been the control table accumulated to a certain extent, it can meet the needs of clinicians writing diagnosis, can facilitate the medical records, statistics and other departlnents work. This disease automatic coding in the medical process scheme is worth further study and promotion.
出处
《中国数字医学》
2013年第12期95-97,共3页
China Digital Medicine
关键词
病案首页
自动编码
ICD—10疾病诊断
home page of medical records, autocode, ICD-10, disease diagnosis
