疾病编码对中医临床路径实施的影响  

Impact of Disease Code on Traditional Chinese Medicine Clinical Pathway

作　　者：王春容[1] 曾宇平[2] 

机构地区：[1]广州中医药大学第一附属医院 [2]广东省中医院

出　　处：《中国病案》2012年第2期31-32,共2页Chinese Medical Record

摘　　要：临床路径的有效实施依赖于准确的疾病编码和出入路径标准,中医病证分类与代码和国际疾病分类对此作了有力的保障。中医临床路径疾病编码的特点,主要表现在中、西医编码并存、疾病名称包含一组疾病、不同路径相同编码等八个方面;分析发现中医临床路径编码工作中仍然存在编码不准确、编码不能满足临床需要、诊断书写不规范等问题;本文根据问题提出了相应的解决措施,包括编码人员参与临床路径的制定、加强临床医师的病历书写规范、统一临床路径的TCD和ICD-10编码、提高编码人员的专业素质等。Effective implementation of clinical pathways depends on accurate coding of the disease and access paths standards,TCM syndrome classification and code and the International Classification of Diseases have made a strong guarantee.The performance of TCM clinical pathway disease coding features are mainly in Chinese and Western medicine codes co-exist,one name includes a set of diseases,a code concludes different paths and any other eight different aspects.By analyzing the problems such as inaccurate coding,coding can not meet the clinical needs,irregular writing,some measures are proposed such as coders involved in the development of clinical pathways,strengthen the clinician＇s medical writing specifications,uniform the TCD and ICD-10 coding of clinical pathways, improve the professional quality of the coders and so on.

关 键 词：临床路径 疾病编码 疾病分类 

分 类 号：R197.3[医药卫生—卫生事业管理]