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北京某三甲医院建立了临床诊疗技术名称字典库与ICD-10的映射表,并形成定期更新维护机制,实现了计算机系统自动完成临床诊断与ICD-10间转化的工作模式(即“映射模式”)。由此,病案编目工作效率提高,其工作重点和内容改变为临床数据字典维护、病案上报数据的调整与核准、临床数据的汇总和输出、加强病案质控工作。
Beijing a top three hospitals established a dictionary of clinical diagnosis and treatment technology name dictionary and ICD-10 mapping table, and the formation of a regular update maintenance mechanism to achieve a computer system to automatically complete clinical diagnosis and ICD-10 conversion work mode (ie “mapping mode ”). As a result, the work efficiency of medical record cataloging has been improved. The focus and content of the work have been changed to the maintenance of clinical data dictionary, the adjustment and approval of the reported medical record data, the compilation and output of clinical data, and the enhancement of quality control of medical records.