基于知识库的手术操作分类ICD-9-CM3系统设计

电子病历改变了病历载体的存储方式，创新了病案管理模式，其中电子首页的疾病诊断和手术操作信息正确填写成为关注的焦点。手术分类ICD-9-CM3是专业知识、技术性极强的工作，要求熟悉分类编码规则。分析了临床医师在医生工作站填写首页的手术信息，由于跨专业的限制和复杂多样临床情况等因素，常出现各种填写错误的情况，降低了电子病历数据分析与挖掘的准确性，提出只有依靠信息技术，建立基于知识库的手术操作分类（ICD-9-CM3）系统，设计手术操作编码知识库的系统结构及操作流程，对手术信息的填写进行核查、提示和指导，实现正确填写手术信息，达到不断减少错误，提高病案信息资源的利用。

Design of ICD-9-CM3 System of Operation Classification Based on Knowledge Base

Electronic medical record （EMR） has changed the storage mode of medical record carrier and innovated the management mode of medical records. Moreover, the correct fulfillment in disease diagnosis and operation information of the EMR homepage has become the focus of attention. As operation classification ICD-9-CM3 is a task requiring professional knowledge and strong technicality, it demands the personnel to be familiar with classification code rules. This paper analyzes the operation information in the homepage filled out by clinicians at the doctor workstation. Due to the factors like multi-disciplinary limitation as well as complicated and various clinical situations, different filling mistakes will emerge and the correctness of EMP- data analysis and mining will be lowered. Therefore, only by information technology, establishing operation classification （ICD-9-CM3） system based on knowledge base, designing the system structure and operational process of operation code knowledge base, as well as verifying, prompting and guiding the fulfillment of operation information, can the correct fulfillment of operation information be achieved, the mistakes be constantly reduced and the utilization of medical record information resources be improved.