住院电子病历诊断术语管理及效果评价  

Management and Effect Evaluation of Diagnostic Terms of Inpatient Electronic Medical Record

作　　者：赵慧智[1] 王坤锐 王晶晶[1] 王卫卫[1] 刘冰[1] Zhao Huizhi;Wang Kunrui;Wang Jingjing;Wang Weiwei;Liu Bing(Hebei General Hospital,Shijiazhuang 050051,Hebei Province,China;不详)

机构地区：[1]河北省人民医院,河北省石家庄050051

出　　处：《中国病案》2022年第10期29-31,共3页Chinese Medical Record

基　　金：河北省2019年度医学科学研究重点课题计划(20190212)。

摘　　要：目的探讨住院电子病历诊断术语管理方法,评价实施效果。方法通过建立院内诊断库、建立诊断-编码映射关系、建立诊断书写流程并实现智能引用诊断,对诊断术语进行管理。比较改进前(2018年6月1日至2018年6月30日)与改进后(2019年6月1日至2019年6月30日)平均每份出院病历的诊断个数、诊断-编码映射准确率等指标。结果改进后,平均每份病历诊断个数由8.2个增加至9.1个;诊断-编码映射准确率由改进前的61.0%提升至79.5%,提升幅度达18.5%,明显高于改进前(P<0.05)。结论住院电子病历诊断术语管理能够有效规范诊断书写,提高疾病编码质量和效率,减轻编码员负担,是实现临床数据规范化管理“四统一”的有效措施。Objectives To evaluate the effect of management method of diagnostic terms of EMR in the hospital,and evaluate the implementation effect.Methods The management of EMR diagnosis writing was carried out by establishing the clinical diagnosis database in the hospital,establishing the diagnosis code mapping relationship,establishing the diagnosis writing process and intelligent reference diagnosis.12321 discharged medical records before improvement(June 1st,2018 to June 30th,2018)and after improvement(June 1st,2019 to June 30,2019)were selected.The average number of diagnoses per medical record and the accuracy of diagnosis coding mapping were compared.Results Based on 3999 clinical diagnosis verified and Disease classification code national clinical version 1.1,an in-hospital clinical diagnosis database was established.The coder encodes the clinical diagnosis one by one.79.29%of the diagnoses were given accurate coding,16.78%were given general coding,and 3.93%were given common coding according to coding rules and coding experience.Clinicians select clinical diagnosis and generate codes by mapping.After the improvement,the average number of diagnoses per medical record increased from 8.2 to 9.1,the accuracy of diagnostic coding mapping was improved from 61.0%before implementation to 79.5%,with an increase of 18.5%,which was significantly higher than that before implementation(P<0.05).Conclusions The management mode of diagnosis terms of EMR in the hospital could effectively standardize diagnosis writing,improve the quality and efficiency of disease coding,and reduce the burden of coders.It was an effective measure to realize the four unification of standardized management of clinical data.

关 键 词：临床诊断 四统一 住院病案首页 住院电子病历 医学名词 

分 类 号：R197.323[医药卫生—卫生事业管理]