肿瘤类疾病临床诊断术语集的构建与实践  

Construction and Practice of Clinical Diagnosis Terminology of Tumor Diseases

作　　者：李晓鹏 刘思涵 段晓瑾[1] 冯佳琪 李书梅[1] Li Xiaopeng;Liu Sihan;Duan Xiaojin;Feng Jiaqi;Li Shumei(不详;Department of Medical Records,The Fourth Hospital of Hebei Medical University,Shijiazhuang 050011,Hebei Province,China)

机构地区：[1]河北医科大学第四医院病案科,河北省石家庄市050011 [2]河北医科大学第四医院放射治疗科,河北省石家庄市050011

出　　处：《中国病案》2024年第8期19-21,共3页Chinese Medical Record

基　　金：河北省医学科学研究重点课题(20240171)。

摘　　要：针对目前存在肿瘤类疾病诊断不规范,导致疾病分类不准确,影响医疗数据的客观性和科学性的问题,基于国际疾病分类(International Classification of Disease,ICD)分类规则,参考世界卫生组织(World Health Organization,WHO)各系统肿瘤分类,并以国家临床版编码库为框架,构建一个规范的、全面的肿瘤类疾病临床诊断术语集,逐步应用于临床实践,并实时进行更新维护。通过构建此临床诊断术语集,规范了医师的疾病诊断书写,使疾病分类更加准确,为公立医院绩效考核、医保付费、医院管理和科研教学等领域提供更加准确和标椎化的数据。In view of the current problems of unstandardized diagnosis of tumor diseases,resulting in inaccurate Classification of diseases and affecting the objectivity and scientific nature of medical data,based on the International Classification of Disease(ICD)classification rules,A standardized and comprehensive terminology set for clinical diagnosis of tumor-related diseases was constructed with reference to the classification of various systems of the World Health Organization(WHO)and the national clinical edition coding database as the framework,which was gradually applied to clinical practice and updated and maintained in real time.By constructing this clinical diagnosis terminology set,doctors'writing of disease diagnosis is standardized,disease classification is more accurate,and more accurate and standardized data is provided for public hospital performance assessment,medical insurance payment,hospital management,scientific research and teaching and other fields.

关 键 词：肿瘤 临床诊断术语 WHO肿瘤分类 ICD-10 

分 类 号：R197.323[医药卫生—卫生事业管理]