军用标准《手术和操作分类与代码》字典库的建立  

Establishment of Dictionary Database of GJB Classification and Codes for Surgery and Operation

作　　者：刘克新[1] 郑琳[1] 林海丽[1] 范炜然[1] 胡湖[2] 柏朝青[1] 王莹[1] 李萌[1] 王建玥[1] 

机构地区：[1]解放军总医院病案管理科,北京100853 [2]总后卫生部信息中心,北京100842

出　　处：《解放军医院管理杂志》2014年第3期206-207,共2页Hospital Administration Journal of Chinese People's Liberation Army

摘　　要：目的建立国家军用标准《手术和操作分类与代码》字典库,修订国家军用标准GJB 3129-1997《手术操作名称与代码》。方法通过各种途径征求各驻京医院临床科室意见,向全军80家医院发送《征求意见稿》,举办全军病案管理学习班及通过邮箱、电话等方式,广泛征求《字典库》使用意见,及时解答反馈问题,修改补充和完善字典库。结果截止2012年底共解答反馈修改意见125条。逐条反复讨论并及时修改完善军标草案,形成军标送审稿,经审查委员会审查,最后修订标准手术操作编码共计8 182条。结论字典库的建立,规范了军队医疗机构手术和操作的名称,颁布后将军队医疗卫生机构手术和操作的信息和数据标准化提供重要依据,满足军队卫生系统医疗、教学、科研和管理的需要。Objective To establish the dictionary database of GJB Classification and Codes for Surgery and Operation,and revise GJB 3129-1997.Methods Taking advice from hospitals in Beijing through various channels,sending exposure draft to 80 hospitals,holding the army medical record management classes and extensively soliciting opinions by email and phone.Solving problems timely,and completing the dictionary databases.Results By the end of 2012,we have answered 125 amendments,revised 8182 standard surgery and operation codes after the committee review.Conclusion The establishment of the dictionary database standard the name of surgery and operation of army medical institutions.It can provide important basis for standardization of information and data of surgery and operation in military health system,and meet the needs of medical treatment,teaching,scientific research and management in military health system.

关 键 词：国家军用标准 手术 分类 代码 字典库 

分 类 号：R197.32[医药卫生—卫生事业管理]