规范疾病诊断名称的必要性  

Necessity of Regulating the Name of Disease Diagnosis

作　　者：柳剑[1] 赵太宏[1] 肖雨龙[1] Liu Jian;Zhao Taihong;Xiao Yulong(Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing 210006, Jiangsu Province, China)

机构地区：[1]南京医科大学附属南京医院,南京市210006

出　　处：《中国病案》2017年第12期23-25,共3页Chinese Medical Record

基　　金：江苏省现代医院管理研究基金资助(JYS-2-2016-061)

摘　　要：规范的疾病诊断名称是疾病正确分类的基础,而准确的疾病分类编码关系到DRGs分组质量及使用后的效果。当前我国各医院疾病诊断名称主要由临床医师根据习惯书写或者以国际疾病分类名称代替疾病诊断名称。规范疾病诊断名称不但可以提高卫生信息标准化程度和疾病分类编码的准确性,还能促进疾病分类管理和应用。通过建立规范化临床诊断字典库或开发结构化诊断系统改进疾病诊断录入策略,再定期开展专题培训可以起到规范疾病诊断名称的作用。The standard name of disease diagnosis is the basis for correct classification of diseases, and accurate classification and coding of diseases are related to the quality of DRGs packets and the effect after use.Therefore, it is very important to standardize the name of disease diagnosis under the new situation of DRGs. At present, the names of disease diagnoses in Chinese hospitals are mainly written by the clinicians according to their habits, or replaced by the name of international classification of diseases.In addition to improving the standardization of health information and the accuracy of disease classification and coding, the standard name of disease diagnosis can also promote the classification, management and application of diseases. Through the establishment of standardized clinical diagnostic dictionary or the development of structured diagnostic system,improvement of disease diagnosis entry strategy, and then carry out regular training, can play a role in standardizing the name of disease diagnosis.

关 键 词：疾病诊断 名称 疾病分类 规范 

分 类 号：R197.323[医药卫生—卫生事业管理]