基于ICD-10编码应用的疾病数据质量管理体系建立

Establishment of Quality Management System in Disease Data Based on the Application of the ICD-10 Coding

目的基于国际疾病分类编码应用,建立综合考虑疾病命名和疾病分类的数据质量管理体系,以规范疾病诊断书写,保证疾病数据质量,客观反映临床现状。方法运用版本差异分析和对照补缺的方法,临床医生在编码员的协助下对本专业类目下的疾病诊断和编码按照一定原则加以扩充。结果院内诊断库和手术操作库健全完善并信息化运用,构建了一种既满足编码规范又便于临床使用的可持续改进的编码模式和疾病质量数据管理体系。结论管理体系可有效推进氤床医学语言的统一,引导病案管理部门的转型,实现临床医生编码的有效培训,夯实医院基础质量,促进医院内涵建设。

Objective Based on the application of the ICD-10 coding, a quality management system in disease data was established, which would contribute to the specification of disease diagnosis and the quality of disease data. Methods Using variance analysis of ICD versions, clinicians in the help of coders would expand disease diagnosis and coding according to certain principles.Results The database of diagnosis and surgery was improved. A kind of coding mode and quality management system in disease data was build, which was easy to use and updated by clinicians and coders.Conclusion The system can promote the unity of the clinical medical language, which has significance for the foundation quality and the content quality of hospitals.