| 摘要: |
| 目的 实现诊断疾病名称和ICD-10（国际疾病分类）同步录入，既能确保编码的正确性又能准确无误地反映出病人病情的真实状态，同时提高ICD-10编码使用率。方法 将ICD码字典库嵌入医院信息系统中医生工作站的电子病历模块中，在病历首页设计一种分层录入模式，整个录入框由诊断主体、诊断前体和诊断补充构成。录入时，由诊断医生采用下拉框的方式，选择所需要的诊断名称和对应的ICD-10编码。结果 疾病诊断形成标准化，同步与ICD-10关联，符合国际标准的疾病诊断表述。打破传统模式，由医生完成诊断主体判断与操作，结果更准确。结论 实时、标准化的数据将极大提高病案数据的挖掘与利用，更好地为医、教、研及医院管理者服务。 |
| 关键词: 国际疾病分类 疾病诊断 编码 |
| DOI： |
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| Research on Real Time，Hierarchical and Relational ICD-10 Disease Diagnosis Model |
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| Abstract: |
| Objective The diagnosis of the disease name and ICD-10 sync input ensure correct coding and accurately reflect the real state of the patient，and improve the utilization of ICD-10 code. Methods embed the ICD code dictionary library into doctor workstation EHR module of the hospital HIS system，design a hierarchical entry mode in the EMR，the input box is composed of main diagnosis，precursor and diagnosis supplement. Entry by diagnosis，doctors use the drop-down box way，ICD-10 diagnostics code names and corresponding selection of desired. Results Standardized diagnostic，synchronized with the ICD-10 Association，will be expressed in line with international standards. This will also break the traditional pattern，completed by doctors diagnosis subject judgment and operation，the results will be more accurate. Conclusion real time，standardized data will greatly improve medical record data utilization，better serve the medicine，teaching，research of the hospital. |
| Key words: international classification of diseases,disease diagnosis,code |
