疾病分类名称取代疾病诊断名称的适宜性探讨  

Discussion on the Suitability of the Replacement of the Disease Diagnosis Name by the Disease Classification Name

作　　者：徐长妍[1] 孙晓萍[1] 王海峰[1] 马洪喜[1] 

机构地区：[1]吉林大学第一医院,长春市130021

出　　处：《中国病案》2013年第5期37-38,共2页Chinese Medical Record

摘　　要：目前国内有些医院的临床医师在填写病案首页时直接采用ICD-10字典库中的疾病分类名称用于临床疾病诊断名称的书写,笔者认为疾病分类名称不能满足疾病诊断名称具体化的要求,不适宜直接取代疾病诊断名称,更不适宜由临床医师完成编码,病案的疾病诊断编码工作应当由专业的病案编码人员完成。在目前国家尚无疾病诊断描述性编码系统的条件下,医院可以考虑依托电子病历平台,逐步建立基于ICD-10字典库的疾病诊断名称字典库,满足临床诊断具体化的要求和临床工作的实际需要。At present, some domestic hospital clinicians use the names of ICD-10 dictionary as disease diagnosis directly when they filling the front sheet of the medical record. The author proposes that the classification of diseases can not meet the specific requirements of the diagnosis and is unsuitable for replacing the disease diagnosis name directly. The coding of the medical records should be completed by the professional staff. In the present state of no disease diagnosis descriptive coding system existing, disease diagnosis name dictionary should be established on the basis of ICD-10 dictionary gradually by means of the electronic medical records system in the hospital to meet the specific requirements of the clinical diagnosis and the actual needs of the clinical work.

关 键 词：疾病分类名称 疾病诊断名称 ICD-10字典库 

分 类 号：R197.3[医药卫生—卫生事业管理]