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实现计算机网络化管理是医院现代化建设的需要,我院病案室充分利用计算机网络的优势,对病案首页的核心疾病诊断编码和手术名称编码的工作进行大胆改革,自2003年1月1日起,由临床医生在各科医生工作站录入病案首页疾病诊断编码与手术名称编码,病案回病案室后,由编码员结合病案核对医生录入的病案首页诊断及编码,发现有不正确处请医生重新录入合格后归档。采用这种工作方法后,解决了临床医生填写诊断这一关键步骤,即诊断术语必须完整准确,提高了医生对ICD-10国际疾病分类的重视,病案室节约了编码工作的人力、物力、占用空间,提高了工作效率。使病案室疾病分类编码工作,由传统的单纯管理型向主动提供服务型的病案信息管理方向转化。
The realization of computer network management is the need of the modernization of the hospital. The hospital case makes full use of the advantages of the computer network to boldly reform the core disease diagnosis code and the operation name code of the case homepage. Since January 1, 2003, By the clinician in the various medical workstations record the medical record Home disease diagnosis code and the name of the surgical code, the medical record case, the coder combined with the medical record to check the medical records of the first page of diagnosis and coding and found to be incorrect, please re-enter the doctor qualified After filing. Using this method of work, clinicians to solve this key step to fill out the diagnosis, that is, diagnostic terminology must be complete and accurate, to improve the doctor’s attention to the ICD-10 international classification of diseases, medical records saved the coding work, material resources, occupation Space, improve work efficiency. So that the classification of disease case coding work from the traditional management of the simple to take the initiative to provide service-oriented medical records information management direction.