临床医师使用疾病分类字典库的调查与分析

Investigation and Analysis on the Disease Classification Dictionary Library Applied by Clinical Doctors

目的通过调查临床医师使用疾病字典库的情况,探讨提高临床医师使用疾病分类字典库的方法。方法对2013年3月份2987份电子病案首页中的"出院主要诊断"进行全样本调查,同时,采用随机抽样方法对78位临床医师开展问卷调查并进行统计。结果在2987份病案首页的"出院主要诊断"调查中,只有9.9%的主要诊断使用了疾病分类字典库,医师不使用字典库的主要原因中字典库名称不全或有误占53.9%,系统操作不方便占43.4%,操作不熟练占28.9%。结论加强疾病分类知识培训、规范临床诊断名称、完善字典库和系统操作方法是提高疾病分类字典库使用效率的主要方法。

Objective To investigate the method of improving the application of disease classification dictionary library applied by clinical doctors through conducting survey the current application state. Methods The main diagnosis of home pages in 2987 electronic medical records in March 2013 were conducted sampling survey. And at the same time, 78 doctors were investigated by questionaires by random sample method and made statistical accounting. Rueults In the survey of main diagnosis in home pages of 2987 cases , only 9.9% of diagnosis applied the disease classification dictionary library. The main reasons for the doctors did not use the dictionary li- brary were that the dictionary library name was not complete and incorrect （53.9%）, system of the operation was not convenient （43.4%）, operation was not skilled（28.9% ）. Conclusions The main method of increasing the application efficiency of disease classi- fication dictionary library are strengthening disease classification knowledge training, using standard name of diagnosis and perfecting the dictionary library of disease classification and system operating methods.