随着医疗信息技术的发展,病案首页是病案的核心数据,疾病诊断又是病案首页的关键信息, ICD-10编码工作日趋重要,提高编码质量和效率是首要任务,因此设计基于电子病历的临床疾病ICD-10分类系统已经成为发展趋势.以广东省某医院统计病案管理系统的ICD-10字典库数据为基础,以电子病历系统为依托,运用Java技术和Oracle数据库技术,建立符合临床医师思维的ICD-10疾病诊断编码库,设计智能化的临床疾病ICD-10分类系统.该系统一方面创新了病案疾病分类编码的工作模式,提高了编码质量和效率;同时对疾病诊断名称进行规范和标准化,提高了病历书写质量和效率,提高病案信息资源的利用.%With the development of medical information technology, medical record home is the core data of the medical record, and disease diagnosis is the medical record key, ICD-10 encoding is becoming more and more important, to improve the encoding quality and efficiency is the primary task. Therefore, the design of clinical disease ICD-10 classification system based on electronic medical records has become the development trend. Design on the statistical record management system in Guangdong province hospital ICD-10 disease classification dictionary table data based on electronic medical record system based on the use of Java technology and Oracle database technology, to establish the diagnosis of ICD-10 disease encoding clinicians thinking, clinical disease classification system ICD-10 intelligent design. The system innovation of medical record classification of diseases encoding work mode, greatly improving the encoding quality and efficiency; at the same time of diagnosis standard, improve the quality and efficiency of medical records, improve the utilization of medical record information resources.
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