中国数字医学
中國數字醫學
중국수자의학
CHINA DIGITAL MEDICINE
2014年
4期
55-57
,共3页
方永平%云凤羽%黄建军%马伟东%连晓丹%陈虹%黄彩莲%潘志新
方永平%雲鳳羽%黃建軍%馬偉東%連曉丹%陳虹%黃綵蓮%潘誌新
방영평%운봉우%황건군%마위동%련효단%진홍%황채련%반지신
疾病诊断%国际疾病分类%ICD码字典库%流程%标准
疾病診斷%國際疾病分類%ICD碼字典庫%流程%標準
질병진단%국제질병분류%ICD마자전고%류정%표준
disease diagnosis%international classification of diseases%ICD code dictionary library%process%standard
目的：规范病案首页医生疾病诊断的书写，为按病种付费打好基础。方法：将ICD码字典库嵌入医院HIS系统中医生工作站的电子病历模块中，病案首页疾病诊断由临床医生选择ICD码字典库疾病名称形成。结果：临床医生的疾病诊断更加规范、统一、科学，为病案首页提供更加完善、可靠的基本数据。结论：病案首页疾病诊断的书写使用国际疾病分类的疾病名称能够实现信息数据共享，提高医院的信息化程度，加速数字化医院建设。
目的：規範病案首頁醫生疾病診斷的書寫，為按病種付費打好基礎。方法：將ICD碼字典庫嵌入醫院HIS繫統中醫生工作站的電子病歷模塊中，病案首頁疾病診斷由臨床醫生選擇ICD碼字典庫疾病名稱形成。結果：臨床醫生的疾病診斷更加規範、統一、科學，為病案首頁提供更加完善、可靠的基本數據。結論：病案首頁疾病診斷的書寫使用國際疾病分類的疾病名稱能夠實現信息數據共享，提高醫院的信息化程度，加速數字化醫院建設。
목적：규범병안수혈의생질병진단적서사，위안병충부비타호기출。방법：장ICD마자전고감입의원HIS계통중의생공작참적전자병력모괴중，병안수혈질병진단유림상의생선택ICD마자전고질병명칭형성。결과：림상의생적질병진단경가규범、통일、과학，위병안수혈제공경가완선、가고적기본수거。결론：병안수혈질병진단적서사사용국제질병분류적질병명칭능구실현신식수거공향，제고의원적신식화정도，가속수자화의원건설。
Objective: To standardize the diagnosis of disease in the first page of medical record, Lay a good foundation for DRGs. Methods: ICD (international classification of diseases) code dictionary library was embedded in the electronic medical workstation record modules of the HIS, The first page of medical records of disease diagnosis is formed by clinicians in the selection of the name ICD code dictionary library disease. Results: The diagnosis of diseases in my hospital medical record was more standardized and uniformed, which provided more impeccable and reliable basic data contents to the first page of medical record. Conclusion:Application of International Classification of Diseases to the diagnosis in medical record can realize the information and data sharing in the network. And improve the level of the hospital information, and accelerate the construction of the digital hospital.
