【作者】 刘奎； 李炎； 蒋莉； 魏绍明； 郭建新；

【Author】 LIU Kui;LIYan;JIANG Li;WEI Shao ming;Fifth Affiliated Hospital of Xinjiang Medical University;

【机构】 新疆医科大学第五附属医院；

【摘要】 目的探讨如何利用现有的病案管理软件系统完成2011版《三级综合医院评审标准及实施细则》中第七章部分监测指标的检索,并对检索条件及工作中遇到的问题展开讨论。方法将指标体系中给出的条件与病案科实际编码工作相结合,把描述性文字转化为疾病编码或手术编码,分析条件间的逻辑关系并在病案管理系统中设置逻辑检索式,实现指标数据的获取。结果通过某院构建的HIS平台,病案管理软件能实现绝大多数指标数据的准确获得,对于需要再次进行数据挖掘的重点疾病等统计指标,病案管理人员除了需要对已给出的条件有一定程度的理解外还应密切结合工具书明确疾病的分期、分型,将指~1标体系中遗漏的编码进行补充。结论病案编码人员在进行疾病编码时不仅要对分类系统的分类特点有一定程度的了解外,也要对本院临床疾病诊断书写的实际情况、疾病谱的变化有一定的了解,同时要具备将评审细则中所给出的检索条件转化为编码的能力,在面对临床疾病诊断信息进行编码时要从多个角度出发,综合考虑。更多还原

【Abstract】 Objective Explore how existing case management software system to complete the "three general hospital accreditation standards and implementation details" to retrieve part of the monitoring indicators of Chapter Ⅶ of the 2011 edition,and discuss job search conditions and problems encountered.Methods The indicator system conditions given in Section actual medical record coding combining descriptive text to convert into a disease or surgery coding,analysis of the logical relationship between the conditions set logic to retrieve the formula in case management systems,data acquisition targets.Results Obtain the accurate HIS data platform through the medical record management software can realize the vast majority of index data,the need for re mining focuses on diseases and other statistical indicators,the medical record practitioners need to have given conditions has a certain degree of understanding and should be closely integrated tool clear disease staging,typing,will the omission of the index system of the code was added.Conclusion Disease coders not only to the classification system classification features a certain degree of understanding of the disease during the encoding of the actual situation in our hospital have written diagnosis,disease changes have a certain understanding and to have the same level of hospital accreditation Conditions given search condition into coding ability,in the face of the clinical diagnosis of disease encode information from multiple angles of view,Comprehensive consideration.更多还原