国际疾病分类在病历档案疾病诊断书写中的应用

目的规范病案首页中疾病诊断的书写,使疾病诊断的书写更加科学化、标准化和规范化,促进医院信息化的建设。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,采用ICD-10疾病诊断规范病案疾病诊断书写,不断补充完善ICD码字典库。结果我院病案的疾病诊断名称更加规范、统一,为病案首页提供更加完善、可靠的基本数据内容,实现网络信息数据共享。结论病案疾病诊断的书写使用国际疾病分类的疾病诊断能够提高医院的信息化程度,加速数字化医院建设的步伐。

Application of international classification of diseases to the diagnosis in medical record

Objective To standardize the diagnosis of disease in the first page of medical record,and to make the diagnosis more scientification,standardization and regularization,and to promote the construction of hospital information.Methods international classification of diseases(ICD) code dictionary library was embedded in the electronic medical workstation record modules of the hospital information system(HIS),ICD-10 diagnostic criterion was used for writing disease diagnosis in medical record,and ICD code dictionary library was supplied continuously.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,and realized the information and data sharing in the network.Conclusion Application of international classification of diseases to the diagnosis in medical record can improve the level of the hospital information,and accelerate the construction of the digital hospital.