疾病编目历史的考证方法与意义  

The Method and Significance of Textual Research on the History of Disease Coding

作　　者：金云霞[1] 郭萍[2] 张晴晴[3] 边鹏[3] 

机构地区：[1]山东省血液中心,济南市250014 [2]华北石油管理局总医院,任丘市062552 [3]山东大学附属省立医院统计与病案管理科,济南市250021

出　　处：《中国病案》2017年第8期39-41,共3页Chinese Medical Record

摘　　要：病案信息管理是当前医院管理的重要组成部分。病案作为医疗信息的重要资源,为临床、教学、科研和医院精细化管理、科学决策提供了宝贵的第一手资料,成为新医改重要的抓手。整理某院自1949年建国以来存档的病案,对历史病案进行数字化扫描,同时采用ICD-10和ICD-9-CM-3对历史病案进行疾病和手术编码的补录。历史病案是医学资料的传承载体,通过历史病案了解医学的变化形势,为目前的编码工作提供借鉴和支撑。数据的延续反映出医院病案管理发展的历史轨迹,具有重要的历史、艺术和科学价值和历史传承的意义,弥足珍贵。Medical information management is an important part of the current hospital management. Medical records as an important resource of medical information provides valuable first-hand information for clinical, teaching, scientific research and hospital fine management, scientific decision-making. It has become an important starting point for the new medical reform. Medical records of a hospital since the founding of the people＇s Republic in 1949 were collated, and digital scanned. At the same time using ICD-10 and ICD-9-CM-3 to encode diseases and operations of historical records records. Historical medical record is the carrier for medical information, through the history medical records to understand the changes of the situation and to provide reference and support for the current coding work. The continuation of the data reflects the history of the development for hospital medical record management, with important historical, artistic and scientific value and the significance of historical heritage.

关 键 词：病案管理 编码 历史考证 意义 

分 类 号：R197.323[医药卫生—卫生事业管理]