国际疾病分类(ICD-10)与临床疾病诊断存在问题的探析  

Study on the existential problems of international classification of disease and clinical diagnosis of disease

作　　者：陈晓红[1] 

机构地区：[1]潮州市中心医院,广东潮州521000

出　　处：《现代医药卫生》2004年第22期2348-2349,共2页Journal of Modern Medicine & Health

摘　　要：目的 :探讨临床医生对疾病诊断更标准化、规范化 ,适应国际疾病分类 (ICD -10)在临床的应用。方法 :分析我院2002年以来 ,应用国际疾病分类过程中与临床疾病诊断之间存在的问题。结果 :存在主要疾病诊断选择错误 ,滥用“术后”作第一诊断 ,没有写“组织类型”肿瘤的诊断 ,随意用症状和体征代替诊断 ,没有写外部原因中毒或损伤的疾病的问题。并对存在问题提出几点改进建议。结论 :临床疾病诊断的标准化和规范化 ,可增加编码正确率 ,提高国际疾病分类水平。Objective:To standardize the clinician's diagnosis,so as to fit in with the application of international classification of disease(ICD)in the clinical diagnosis.Methods:The existential problems in the application of ICD and clinical diagnosis of disease since2002enˉcountered in our hospital were analysed.Results:The existential problems were as follows:wrong selection of main disease for diagnosis,misusing the”post-operation”for first diagnosis,no report for”morphology of neoplasm”tumor for diagnosis,substituting physical symptom or sign for diagnosis,no report for poisoning or damage from external causes.Then some suggestions were put forwared for improvement of these probˉlems.Conclusion:The standardization of clinical diagnosis of disease can increase the accurate rate of coding and improve the level of international classification of disease.

关 键 词：疾病诊断 国际疾病分类 临床疾病 ICD-10 肿瘤 临床的应用 症状和体征 探析 结论 正确率 

分 类 号：R197[医药卫生—卫生事业管理] R734.2[医药卫生—公共卫生与预防医学]