采用ICD-10字典规范门诊疾病诊断  

Applying ICD-10 Dictionary to Standardize Outpatient Disease Diagnosis

作　　者：李阳[1] 张志忠[1] 张乐辉[2] 

机构地区：[1]首都医科大学附属北京友谊医院病案科,北京市100050 [2]首都医科大学附属北京友谊医院医务部,北京市100050

出　　处：《中国病案》2011年第5期27-29,共3页Chinese Medical Record

摘　　要：目的采用ICD-10疾病诊断标准,规范了门诊医师工作站疾病诊断字典库,便于医师使用,利于HIS系统、医保付费、科研、统计等工作。方法将HIS系统中的疾病字典更新为国际疾病分类(ICD-10),规范门诊诊断,同时制定措施保障新疾病字典成功启用。结果门诊医师工作站成功实现疾病字典切换,增加和规范了门诊诊断,方便了医师操作,提高了管理水平,为今后工作奠定了坚实基础。结论通过此项工作,提高了门诊管理水平、规范了门诊诊断、保证了医保上传疾病数据的准确性,并且为门诊疾病分类、数据分析等工作打下坚实基础。Objective It standardizes disease diagnosis dictionary database of outpatient clinicians station by applying ICD-10 disease diagnosis,which access to doctor and is benefit to HIS system,medical insurance payment,scientific research and statistics and etc.Methods Disease dictionary in HIS system is updated to ICD-10 in order to standardize outpatient diagnosis and draft countermeasures for making sure the new disease dictionary success operation.Results Station of outpatient clinicians successfully realize disease dictionary shifting that increase and standardize outpatient disease,easy for operation by doctors,improving management level and settling solid foundation for future work.Conclusions Through this work,it not only enhances management level of outpatient service,standardizes diagnosis of outpatient service and makes sure the accuracy of uploading disease data of medical insurance;but also sets solid foundation for disease classification of outpatient service and data analysis and etc.

关 键 词：门诊诊断 门诊医师工作站 疾病字典 ICD-10 

分 类 号：R197.3[医药卫生—卫生事业管理]