《中国临床疾病诊断规范术语集》的临床应用与实践

The Application and Practices of Chinese Clinical Diagnosis Terminology

《中国临床疾病诊断规范术语集》作为C-DRG体系中的重要分组工具之一,由全国37个专业735名国家级临床专家结合中国临床教学和临床应用的实践制定而成。术语集一病一码,每一条诊断术语均与《2016版疾病分类与代码》(GB/T 14396-2016)每一个词条进行了对接,以确保试点地区选用的诊断术语在病案统计上对应的是一条ICD-10疾病分类词条。本术语集中增入了罕见病相关术语,最大化覆盖临床全诊断。作为DRG分组的重要基础工具之一,《中国临床疾病诊断规范术语集》应当由临床医生在电子病历中进行勾选,配合信息系统改造使用。在医院应用术语集有助于医院之间信息标准的统一、信息流程的优化,从而加强医院的精细化管理。

Chinese Clinical Diagnosis Terminology(CCDT) is one of the important grouping tools in the C-DRG system, which is designed by 735 national clinical experts from 37 specialties in the country combined with Chinese clinical teaching and clinical application practices. The terminology is mapped with the ICD-10 national standards(2016 version), which realizes one disease has one unique code. Rare diseases are added to the terminology. As one of the basic tools for grouping, the terminology should be selected by clinicians in the electronic medical record combined with health information system transformation. Applying the terminology in the hospital helps the unification of information standards and the optimization of information process, so as to strengthen the refined management of hospitals.