基于疾病分类与代码的上海市传染病报告标准编码的建立  

Establishment of standard coding for Shanghai infectious disease report based on disease classification and code

作　　者：王晔[1] 陶芳芳[1] 冯玮[1] 吴寰宇[1] 

机构地区：[1]上海市疾病预防控制中心,上海200336

出　　处：《上海预防医学》2018年第8期663-667,共5页Shanghai Journal of Preventive Medicine

基　　金：上海市卫生和计划生育委员会地方卫生标准预研制项目(标2017-3)

摘　　要：【目的】为规范传染病报告要求,提升传染病报告效率与质量,基于疾病分类与代码的应用,建立适用于上海市医疗机构传染病报告的标准编码。【方法】经过调研问卷、文献查阅、专家咨询等方式,整理传染病的病种表,收集传染病病种相应诊断名称,将选取的疾病分类与代码与传染病病种进行逐一匹配。通过一对多、多对一以及增加提示条件关系等方法,梳理出基于疾病分类与代码的上海市传染病报告标准编码库。【结果】通过疾病分类代码与传染病报告病种的关系对应,形成一套便于医疗机构使用的可持续改进的基于疾病分类代码的传染病报告标准编码,并应用于上海市传染病报告管理信息系统试点工作。【结论】本次研究的标准编码可应用于上海市传染病报告信息系统,作为传染病诊断触发报告的基础,改变传统的传染病报告模式,对推进传染病疫情报告管理信息化工作有重要的意义。[Objective]In order to standardize the reporting requirements of infectious diseases and improve the efficiency and quality of infectious disease reporting,based on the application of disease classification and code,the standard coding is set up for infectious disease reporting applicable to Shanghai medical institutions. [Methods]Disease tables of infectious diseases were sorted out,corresponding diagnosis names of infectious diseases collected, and selected disease classification and codes matched with infectious diseases. The standard library for infectious diseases based on disease classification and code was combed through the correspondence of one to many,many to one,and the increase of the relationship of prompting conditions. [Results]Through corresponding relationship between disease classification and disease entities in infectious disease report, based on the standard encoding of infectious disease report with disease classification code,a set of easy-to-use standard coding was formed for medical institutions,which could be used for sustainable improvement and applied to the pilot work of infectious disease report management information system of Shanghai city. [Conclusion] The standard coding in this study can be applied to the information construction of infectious diseases report in Shanghai. It is the basis of the report for diagnosis of infectious diseases, and the change of the coding for traditional infectious disease report is of great significance in promotion of the information management of infectious disease reports.

关 键 词：疾病分类与代码 传染病报告 标准 编码 

分 类 号：R138[医药卫生—劳动卫生]