临床疾病诊断的描述与主要诊断的选择原则  

Description of clinical diagnosis of diseases and selection principle of major diagnoses

作　　者：吴良明[1] 

机构地区：[1]南京大学医学院附属鼓楼医院,210008

出　　处：《中华医院管理杂志》2001年第4期231-233,共3页Chinese Journal of Hospital Administration

摘　　要：ICD 10分类编码在我国开始推行。因此 ,临床医师应合理描述疾病诊断 :①强调诊断的特异性 ;②不明确的情况强调症状或体征 ;③享受医疗服务的项目可作为诊断。④需要描述引起损伤或中毒的外因情况 ;⑤需要描述后遗症的表现及病因。另外从With the promotion of ICD 10 in China, it is necessary for clinicians to rationally describe their diagnosis of diseases. They should stress the specificity of each diagnosis and the symptoms or signs in case of uncertain cases. They may regard medical service items as diagnoses and should describe the external causes of injuries or poisoning and the manifestation and pathology of sequels. In addition, the paper explains from 5 aspects the selection principle of the major diagnoses of diseases.

关 键 词：临床疾病诊断 描述主要诊断 选择原则 ICD-10 

分 类 号：R44[医药卫生—诊断学]