临床病理诊断结果分类信息代码系统的设计和应用  

To Design and Actualize the Information Coding Solution to the Clinical Pathological Diagnosis Classification System

作　　者：杜祥[1] 施达仁[1] 李小秋[1] 夏川江[2] 朱雄增[1] 王坚[1] 陈忠伟[1] 苏鹏[2] 

机构地区：[1]复旦大学附属肿瘤医院病理科,上海200032 [2]复旦大学附属肿瘤医院信息科,上海200032

出　　处：《复旦学报（医学版）》2004年第6期622-624,660,i012,共5页Fudan University Journal of Medical Sciences

摘　　要：目的　规范、精确疾病定义。方法　采用多项分类内容定义疾病或形态学改变。数据库设计采用SQLSERVER 2 0 0 0数据库。结果　确立临床病理诊断结果分类信息 9位核心代码 +2位附加代码系统的方案。核心代码本质为疾病属性分类命名编码 ,包含了“性质分类”、“生物行为”、“组织起源”、“形态归类”及“诊断名称序号”等。附加代码包括“标本来源”、“病理类别”两项。结论　病理诊断结果代码库可与国际医学规范术语集(SNOMED International)及国际疾病分类 (ICD)代码相对应 ,方便国内外同行进行医学信息通讯和交流 ,对推广医院信息系统标准编码 。Purpose: To design a standardization system to define diseases precisely. Methods: Multiple classifying contents are employed to define diseases or morphological changes. SQL SERVER 2000 database is applied to design database. Results: The coding solution to the clinical pathological diagnosis classification is established on a 9-digit core code plus a 2-digit add-on code system. The core code stands for the classification code of the disease's nature which includes 'property classification', 'biological behavior', 'histological origin', 'morphological classification' and 'diagnostic nomenclature number'. The add-on code consists of 'sample source' and 'pathological sort'. Conclusions: Pathological diagnosis code database can be corresponding to the SNOMED-International (Systematized Nomenclature of Human and Veterinary Medicine) and the International Classification of Diseases (ICD) code. It will facilitate the communication of medical information among internation peers and exert positive influences on the popularization of standard code of hospital information system and the standardization of pathological diagnosis.

关 键 词：临床病理诊断 国际疾病分类 组织起源 形态学改变 生物行为 行医 诊断名称 确立 核心 积极意义 

分 类 号：R197[医药卫生—卫生事业管理] R329-33[医药卫生—公共卫生与预防医学]