研究以ICD-10为基础的诊断智能自动编码系统的临床应用

Study on the Clinical Application of the Diagnostic Intelligent Automatic Coding System Based on ICD-10

目的分析以ICD-10为基础的诊断智能自动编码系统的临床应用情况。方法对该院临床诊断数据库以及扩充的ICD-10字典库进行更新和完善,选择2014年1月-2020年1月期间该院电子病历医生工作站中的历史诊断数据编码,临床诊断中录入疾病的总数量为20000例,分析通过智能自动编码系统进行编码的成功率。结果经过研究发现,临床诊断中录入疾病的总数量为20000例,能够进行自动编码的诊断数量为19200例,所以通过智能自动编码系统进行编码的成功率为96%。结论以ICD-10为基础的诊断智能自动编码系统的临床应用效果显著,能够进一步规范和完善临床对于疾病类型编码情况,扩充临床诊断字典库,能够有效地提高医院各项工作的进展效率,值得进一步研究和发展。

Objective To analyze the clinical application of the diagnostic intelligent automatic coding system based on ICD-10.Methods The clinical diagnosis database and the expanded ICD-10 dictionary database of this hospital were updated and improved.The historical diagnosis data codes in the electronic medical record doctor workstation of the hospital from January 2014 to January 2020 were selected,and the total number of diseases entered in clinical diagnosis was 20000,and the success rate of coding through the intelligent automatic coding system was analyzed.Results After research,it was found that the total number of diseases entered in clinical diagnosis was 20000,and the number of diagnoses that could be automatically coded was 19200,so the success rate of coding through the intelligent automatic coding system was 96%.Conclusion The clinical application effect of the diagnostic intelligent automatic coding system based on ICD-10 is significant,which can further standardize and improve the clinical coding of disease types,expand the clinical diagnosis dictionary database,and effectively improve the efficiency of the hospital’s various tasks.It is worthwhile further research and development.