医院精细化管理变革之门急诊电子病历疾病诊断名称与ICD-10编码对应性研究  

A study on the correspondence between disease diagnosis and ICD-10 code in outpatient and emergency EMRS in the reform of hospital fine management

作　　者：滕燕飞 吴韫宏 何美娜[1] 谢叶玲 TENG Yanfei;WU Yunhong;HE Meina;XIE Yeling(The Second Affiliated Hospital of Guangxi Medical University,Nanning 530007,China;不详)

机构地区：[1]广西医科大学第二附属医院,广西南宁530007

出　　处：《现代医院》2020年第9期1335-1338,共4页Modern Hospitals

基　　金：广西壮族自治区卫生健康委员会自筹经费科研课题(Z20200818)。

摘　　要：随着医疗改革的推进,病案数据信息的准确性越来越受到重视,为了规范门急诊医疗行为,使门急诊诊断数据更准确、更有效,保证门急诊病种数据能真正地应用于科教研及医疗管理,同时为Drgs付费和医保系统提供更准确的、及时的、完善的信息。研究以某医院2017—2018年使用的所有门急诊诊断名称为数据基础,通过数据收集清洗、整合分类、审核修订、对应映射、试用补充五个阶段,规范了门急诊电子病历临床诊断名称,并与ICD-10疾病分类编码对应,以标准化医疗数据促进医院精细化管理。Along with the advancement of medical reform,the accuracy of the medical record data information is more and more attention,in order to standardize outpatient and emergency medical behavior,ensure this diagnosis data be more accurate,and can really application service to science research,While providing more accurate,timely,and comprehensive information for the Drugs payment and healthcare systems.Based on the data of all outpatient and emergency diagnosis names used in a hospital during 2017-2018,this study realized standardized and refined management of outpatient and emergency diagnosis through data collection,cleaning,integrated classification,review and revision,corresponding mapping and trial supplement.The hospital standardized the clinical diagnosis name of electronic medical records in outpatient and emergency departments,and corresponding to the classification code of icd-10 diseases,so as to standardize the medical data and promote the fine management of the hospital.

关 键 词：门急诊诊断 国规范化 ICD-10编码 对应映射 

分 类 号：R197.323.1[医药卫生—卫生事业管理]