采用ICD-10字典规范门诊疾病诊断

摘要

目的 采用ICD-10疾病诊断标准,规范了门诊医师工作站疾病诊断字典库,便于医师使用,利于HIS系统、医保付费、科研、统计等工作.方法 将HIS系统中的疾病字典更新为国际疾病分类(ICD-10),规范门诊诊断,同时制定措施保障新疾病字典成功启用.结果 门诊医师工作站成功实现疾病字典切换,增加和规范了门诊诊断,方便了医师操作,提高了管理水平,为今后工作奠定了坚实基础.结论 通过此项工作,提高了门诊管理水平、规范了门诊诊断、保证了医保上传疾病数据的准确性,并且为门诊疾病分类、数据分析等工作打下坚实基础.%Objective It standardizes disease diagnosis dictionary database of outpatient clinicians station by applying ICD- 10 disease diagnosis ,which access to doctor and is benefit to HIS system . medical insurance payment. scientific research and statistics and etc . Methods Disease dictionary in HIS system is updated to ICD-10 in order to standardize outpatient diagnosis and draft counterm easures for making sure the new disease dictionary success operation . Results Station of outpatien t clinicians successfully realize disease dictionary shifting that increase and standardize outpatient disease .easy for operaton by doctors . improving managem ent level and settling solid foundation for future work . Conclusions Through this work , it not only enhances managem ent level of outpatient service . standardEes diagnosis of outpatient service and makes sure the accuracy of uploading disease data of medical insurance ; but also sets solid foundation for disease classification of outpatient service and data analysis and etc .