基于电子病历的临床诊断编码分值库的建立和应用研究

Research on the establishment and application of clinical diagnostic coding score database based on electronic medical records

基于广东省惠州市某三甲综合医院的结构化电子病历系统,将“符合医生逻辑思维的临床疾病诊断库”“ICD-10疾病诊断编码库”“医保病种分值库”三库合一,进而规范、统一医生疾病诊断术语,优化病案编码人员的工作流程,促使医务人员合理诊疗,严格管控医疗费用的不合理增长,以期满足医院医疗质量管理、病案信息化管理、医疗保险付费、医学科研教学等多方面的发展需求,为惠州地区下一步推行疾病诊断相关分类提供借鉴方案。

Based on the structured electronic medical record system of a top three general hospital in Huizhou City,Guangdong Province,the three libraries of"clinical disease diagnosis database that conforms to the logical thinking of doctors","ICD-10 disease diagnosis coding library"and"medical insurance disease score database"are combined into one.In order to standardize and unify the doctor′s disease diagnosis terminology,optimize the work flow of medical record coding personnel,prompt medical personnel to make reasonable diagnosis and treatment,and strictly control the unreasonable growth of medical expenses,with a view to satisfying hospital medical quality management,medical record information management,medical insurance payment,medical research The development needs of various aspects such as teaching provide a reference plan for the next implementation of disease diagnosis-related classification in Huizhou.