门诊疾病诊断名称规范化研究

Study on the standardization of diagnostic name of outpatient diseases

目的分析门诊疾病诊断名称的不规范诊断类型,探讨规范医师书写诊断名称的有效措施。方法回顾性调查分析2007年9月~2014年3月北京大学第三医院门诊疾病诊断名称书写情况。结果导出的门诊诊断中不规范诊断4804条,不规范诊断的类型包括将疾病名称简写(137条)、书写疾病的英文名称(99条)、医学术语不规范(2021条)、诊断名称的顺序颠倒(24条)、诊断不明确或过于详细(1143条)、书写国际疾病分类中未标明的具体解剖部位(1380条)。结论针对门诊疾病诊断名称的不规范类型,精准培训临床医师对规范诊断的临床思维习惯,研究改进疾病分类编码,提高对卫生信息化发展的支持。

Objective To analyze the type of non-standard diagnosis writing of outpatient diseases, and to explore the effective measures for physicians＇ writing standards. Methods A retrospective study was conducted on the outpatient disease diagnosis writing in Peking University Third Hospital from September 2007 to March 2014. Results There were4804 non-standard outpatient diagnosis writing. The types of non-standard diagnosis could be divided into abbreviated disease name（137 items）, disease name written by English（99 items）, non-standardized medical terms（2021 items）,reversed the order of diagnostic name（24 items）, undefined or too detailed diagnosis（1143 items）, and written by nonclassified anatomical site in ICD-10（1380 items）. Conclusion In view of the irregular type of diagnosis writing of outpatient diseases, the clinicians should be trained to standardize the clinical thinking habits, improve the classification of diseases and promote the support of health information development.