医生工作站病案疾病诊断书写中ICD-10编码的应用

Application of ICD-10 in the Diagnosis in Medical Record in Doctor Workstation

目的:规范病案首页医生疾病诊断的书写,为按病种付费打好基础。方法:将ICD码字典库嵌入医院HIS系统中医生工作站的电子病历模块中,病案首页疾病诊断由临床医生选择ICD码字典库疾病名称形成。结果:临床医生的疾病诊断更加规范、统一、科学,为病案首页提供更加完善、可靠的基本数据。结论:病案首页疾病诊断的书写使用国际疾病分类的疾病名称能够实现信息数据共享,提高医院的信息化程度,加速数字化医院建设。

Objective： To standardize the diagnosis of disease in the first page of medical record, Lay a good foundation for DRGs. Methods： ICD （international classification of diseases） code dictionary library was embedded in the electronic medical workstation record modules of the HIS, The first page of medical records of disease diagnosis is formed by clinicians in the selection of the name ICD code dictionary library disease. Results： The diagnosis of diseases in my hospital medical record was more standardized and uniformed, which provided more impeccable and reliable basic data contents to the first page of medical record. Conclusion： Application of International Classification of Diseases to the diagnosis in medical record can realize the information and data sharing in the network. And improve the level of the hospital information, and accelerate the construction of the digital hospital. Keywords disease diagnosis, international classification of diseases, ICD code dictionary library, process, standard