疾病诊断名称与分类编码对照对提升病案首页质量的意义  

Significance of the Comparison of Disease Diagnosis Name and Classification Code to Improve the Quality of the First Page of Medical Records

作　　者：李玉萍[1] LI Yu-ping(Medical Record Room,Changping District Hospital,Beijing 102200,China)

机构地区：[1]北京市昌平区医院病案室,北京102200

出　　处：《医学信息》2020年第9期17-18,共2页Journal of Medical Information

摘　　要：病案首页是对住院病案信息的综合反映,是医疗管理、统计和临床医学研究的直接信息来源。疾病分类作为报告疾病和健康状况的标准,是病案首页数据的重要组成部分。为了提高医疗数据统计的及时性与准确性,保障病案首页质量,做好疾病诊断名称与疾病分类编码对照具有重要意义。本文通过现状分析、规范诊断名称、标注关键词、首字母以及相关检索流程优化方法,强化疾病诊断名称与疾病分类编码对照,提升疾病分类编码的准确性,使临床医生快速便捷查找疾病诊断名称与相对应的疾病分类编码,进而提升病案质量,更好的为临床服务,最大化发挥病案的价值。The medical record homepage is a comprehensive reflection of the information of inpatient medical records, and is a direct source of information for medical management, statistics and clinical medical research. As a standard for reporting diseases and health conditions, disease classification is an important part of the data on the first page of medical records. In order to improve the timeliness and accuracy of medical data statistics, and to ensure the quality of the first page of medical records, it is of great significance to do a good job of comparing the names of disease diagnosis and disease classification codes. This article analyzes the status quo, standardizes diagnostic names, annotates keywords, initials, and related search process optimization methods, strengthens the comparison of disease diagnosis names and disease classification codes, improves the accuracy of disease classification codes, and enables clinicians to quickly and easily find disease diagnosis names and corresponding disease classification codes,thereby improving the quality of medical records, better serving clinical, and maximizing the value of medical records.

关 键 词：疾病诊断名称 分类编码 病案首页 质量 

分 类 号：R197.323[医药卫生—卫生事业管理]