摘要
北京某三甲医院建立了临床诊疗技术名称字典库与ICD-10的映射表,并形成定期更新维护机制,实现了计算机系统自动完成临床诊断与ICD-10间转化的工作模式(即"映射模式")。由此,病案编目工作效率提高,其工作重点和内容改变为临床数据字典维护、病案上报数据的调整与核准、临床数据的汇总和输出、加强病案质控工作。
A mapping table of clinical diagnosis and treatment technology name dictionary library and ICD-10 and its regularly update maintenance mechanism are established in a grade 3 and first-class hospital in Beijing. It can realize the operation mode of computer automatically complete the clinical diagnosis and the conversion between ICD-10. That is mapping mode. Therefore, the coding work of medical record would convert from original data entry and reporting to clinical data updating, maintaining and retrieving, which would play an important role in quality control of medical record, while promoting the working efficiency.
出处
《中国病案》
2015年第2期40-42,共3页
Chinese Medical Record
关键词
映射
编目
定位
Mapping
Code
Orientation
