临床疾病诊断名称标准化的难点与对策

Difficulties and Countermeasures of Standardization of Clinical Diseases Diagnostic Names

临床疾病诊断名称的标准化是卫生信息标准化的一部分,是疾病分类和实施DRGs的基础。现阶段各级医院疾病诊断名称是以国际疾病分类名称代替疾病诊断名称或者由临床医生根据习惯书写疾病诊断。在疾病诊断名称标准化过程中面临的困难主要有:疾病诊断名称过粗或过细,同一种疾病各专科书写要求不同,复杂的疾病诊断难以标准化,各类疾病术后表达含义不明。针对存在的困难,结合临床工作实际,提出了组织专家充分讨论,统一疾病诊断名称书写标准,规范疾病术后的表达方式,建立常见疾病诊断名称字典库,开发结构化疾病诊断名称录入系统等对策,以有效实施临床疾病诊断名称的标准化,满足卫生信息标准化的要求。

The standardization of clinical disease diagnostic names is a part of the standardization of health information,and is the basis of disease classification and DRGs.At present,the names of disease diagnosis in hospitals at all levels are replaced by the names of international classification of diseases or written by clinicians according to their habits.The main difficulties in standardizing disease diagnosis names are as follows:The name of disease diagnosis is too extensive or too detailed,different writing requirements of different specialties for the same disease,difficult to standardize complex disease diagnosis,and unclear meaning of expression of various diseases after operation.In view of the existing difficulties and combining with the actual clinical work,this paper puts forward some countermeasures,such as organizing experts to discuss fully,unifying the Writing Standard of Disease Diagnostic Names,standardizing the expression of disease after operation,establishing a dictionary library of common disease diagnosis names,and developing a structured disease diagnosis name input system,so as to effectively implement the standardization of clinical disease diagnosis names and meet the requirements of health information standardization.