结构化报告模块中ICD-10编码的应用改进  

Application and Improvement of ICD--10 Coding System for Department of Radiology in DICOM SR

作　　者：江桂华[1] 陈延[1] 田军章[1] 林楚岚[1] 颜剑豪[1] 郑丽吟[1] 

机构地区：[1]广东省第二人民医院影像科,广东广州510317

出　　处：《实用放射学杂志》2009年第6期885-888,共4页Journal of Practical Radiology

基　　金：基金项目：广东省医学科研基金项目（编号：A2006150）.

摘　　要：目的在结构化报告模块中构建ICD-10编码系统，将ICD-10编码应用于放射科日常报告中。方法利用ICD-10编码光盘版构建编码数据库，采用本院自行开发的结构化报告系统。结果ICD-10编码功能键位于用户界面右侧，界面左侧安排报告模板。对诊断报告完成编码后编码进入右侧空白栏中。建立ICD-10编码报告模板，根据需要添加已编码的诊断报告作为模板。可以直接调用编码后的报告模板以加快编码速度。结论系统可靠、使用方便，可明显提高疾病编码速度及准确性，提高影像诊断工作质量和效率。Objective To construct the ICD--10 coding system in DICOM SR and to apply to routine reports of department of radiology. Methods Function key of ICD--10 coding located in right and report template in left of user interface. Results The completed code of diagnostic reports entered into right blank of user interface. The report template of ICD--10 coding was set up. The codes as report template could be added according instance. The report templates with coding could be transferred directly to improve the speed of coding. Conclusion The system is reliable and easy to use and has increased coding accuracy and speed of diseases. The quality and efficiency of image diagnosis work were raised.

关 键 词：ICD-10编码 放射学信息系统 软件设计 计算机化 

分 类 号：R812[医药卫生—放射医学] R814.49[医药卫生—临床医学]