【作者】 魏雪； 喻刚； 何斌； 钟晓波；

【Author】 Wei Xue;YU Gang;He Bin;Zhong Xiaobo;The Affiliated Hospital of Stomatology,Chongqing Medical University;

【机构】 重庆医科大学附属口腔医院牙体牙髓科；

【摘要】 目的:对牙体牙髓科就诊患者HIS系统诊断名进行统计分析,为把握科室患者内涵及HIS系统诊断名的有效利用提供依据。方法:全年进入科室HIS系统的所有患者,按HIS系统显示的诊断名进行统计分析。结果:(1)全年66人参与诊断,49960人次进入科室HIS系统,其中47950人次有诊断,诊断名174个。牙体牙髓病诊断名83个,44251人次,分别占47.70%和92.29%。其它为牙周病、颌面外科病,黏膜病和正畸修复科病,不属于口腔医学的诊断名仅2个,均为慢性鼻窦炎。(2)在牙体牙髓病中,龋病诊断名13个,6486人次,分别占7.47%和13.53%。牙体硬组织非龋性疾病诊断名37个,4191人次,分别占8.74%和21.25%:牙髓病诊断名16个,14634人次,分别占9.20%和30.52%;根尖周病诊断名17个,分别占9.77%和35.06。(3)在龋病诊断名中,包含有牙列加程度、牙位加程度、组织加程度等诊断名,出现人次最多的是龋齿,4321人次,占66.62%,出现最少的有两个诊断名(分类较细,包含有三个信息),均为1次;在牙髓病16个诊断名中,包含有牙列、牙位、病理、病程等,其中出现人次最多的是慢性牙髓炎,10179人次占75.02%,仅出现1次的诊断名有5个;在根尖周病的17个诊断名中,性质相同诊断名不同的有五种11个诊断名,诊断名中包含牙列、年龄、病程、病理等,出现人次最多的是慢性根尖周炎,10068人次占58.89%,出现1次的诊断名有2个。在牙体硬组织疾病的37个诊断名中,有两个诊断名完全相同;性质相同诊断名不同的有2种4个诊断名,出现了不明病变实质的诊断名一牙体硬组织疾病,诊断名中包含病因、部位、程度等。结论:进人我科的患者绝大多数为本专业患者,其它各科也有进入;我院HIS系统诊断名繁复,医生使用诊断名粗糙,不利于病案管理统计与科学研究。有必要在临床医生和病案管理员共同配合下对诊断名进行梳理,并对医生进行以ICD-10为基础的诊断名使用培训。更多还原

【Abstract】 Objective:To statistical analyze the diagnostic names from the Hospital Information System of patients in endodontics department.So as to provide a basis for grasping the meaning of our department patients and the effective use of diagnosis name of HIS.Methods:The diagnosis name displayed by HIS of all patients are analyzed statistically.Results:Throughout the year,66 dentists involved in the diagnosis,49960 patients entered our department HIS,among them 47950 have diagnosis,and the diagnostic names are 174.Dental disease diagnosis name are 83,patients are 44251,accounting for 47.70%and 92.29%,respectively.The others are periodontal disease,maxillofacial surgery disease,mucosal disease and Orthodontics Prosthodontics disease.Do not belong to the diagnosis of oral medicine name just two,are chronic sinusitis.b)In dental disease,caries diagnosis are 13,patients are 6486,accounting for 7.47%and 13.53%,respectively;Non-carious dental hard tissue disease diagnosis are 37,patients are 4191,accounting for 8.74%and 21.25%,respectively;pulposis diagnosis are 16,and patients are 14634,accounting for 9.20%and30.52%,respectively;Periapical disease diagnosis are 17,and patients are 16810,accounting for 9.77%and35.06%,respectively.c)Caries diagnosis names contain dentition plus degree,teeth plus degree,tissue plus degree,and so on.The most,4321 patients,of diagnosis names were "caries",accounting for 66.62%,and there are two diagnostic names(Category smaller,contains three information) just have one patient respectively.In the 16 diagnosis names of Endodontic,including a dentition,teeth,pathology,duration,etc.The most is chronic pulpitis which have 10179,accounting for 75.02%,and more than five diagnostic names appeared once only.In 17 periapical disease diagnosis names containing dentition,age,duration,pathology,etc.There are 5 kinds of different diagnosis with same nature,containing 11 diagnostic name,and the names appear most is chronic apical:10068 people accounted for 58.89%,and two diagnostic names appear once only.In 37 diagnosis of dental hard tissue disease,there are exactly two diagnostic names;there are 2 kinds of different diagnosis with same nature,containing 4 diagnostic names;There has been a diagnosis with substance of unknown disease- dental hard tissue diseases,and diagnostic name contains the cause,location,extent and so on.Conclusion:The vast majority of patients entering our hospital are endodontics patients other subjects also have entered.Our hospital HIS diagnostics are complicated,and doctors use diagnostic name roughly.This is not conducive to case management statistics and scientific research.Thus it is necessary to sort out the diagnosis name by clinicians and medical record administrators together and to train doctors to use ICD-10-based diagnostic name.更多还原