临床诊断书写规范化方法研究

目的规范临床诊断书写,为DRGs付费制度的实施做准备。方法建立临床诊断字典,临床医师通过电子病历系统从临床诊断字典中选择诊断名称。结果 95%以上的临床诊断名称均来自临床诊断名称字典,保证了临床诊断名称的规范性,同时能够直接与ICD-10编码对应。结论建立临床诊断字典能够规范临床诊断的书写,同时为提高临床诊断编码的准确性奠定了基础。

Method Research of .clinical D.iagnosis Writing Standardization

Objective To standardize the clinical diagnosis, and make preparation for the Diagnosis Related Groups Payment System. Methods Establishing a clinical diagnosis dictionary. Then, doctors select the clinical diagnosis from the clinical diagnostic dictionary in the electronic medical record system. Results More than 95% of the clinical diagnosis names are from clinical diagnosis name dictionary. It is sure that the clinical diagnosis are more and more normative, meanwhile, they have clear and definite relevance with the lOth International Classification of Diseases. Conclusion To establish a clinical diagnosis of dictionary library is able to standardize clinical diagnosis writing, and lays a solid foundation to improve the accuracy of clinical diagnosis codes.