基于电子病历临床疾病分类系统的应用

Application of Classification System for Clinical Diseases Based on Electronic Medical Records

目的探讨临床疾病分类系统在电子病历中的应用。方法通过建立临床诊断与ICD-10对照表,设计、研发符合临床习惯的疾病分类编码系统,并嵌入电子病历平台,实现智能、自动化编码。结果使用临床疾病分类系统的编码空置率及错误率分别为11.83%,5.13%,结合编码员审核后最终的编码错误率为1.58%。结论电子病历中疾病诊断分类系统的应用可以优化编码流程,提高编码质量和效率,进一步发挥病案信息在医疗、科研及教学中的重要作用。

Objective To explore the application of classification system in electronic medical records. Methods Through the establishment of clinical diagnosis and icd-10 comparison table, design, research and development in line with clinical habits of disease classification and coding system, and embedded in the electronic medical record platform to achieve intelligent, automated coding. Results The vacancy rate and error rate of the clinical disease classification system were 11.83%, 5.13%, and the final coding error rate was 1.58%. Conclusion The application of ICD-10 classification system in electronic medical records can optimize the coding process, improve the coding accuracy and further play the important role of medical record information in medical, scientific research and teaching.