ICD-10北京临床版的设计与实现.pdfVIP

ICD-10北京临床版的设计与实现 黄锋 陈剑铭 郭默宁 张修梅 胡牧 [摘要]通过对疾病分类系统结构的修改，建立临床版模型，并以此为框架，在汇总、整理北京地区 实际在用临床诊断名称及编码的基础上，制定标准编码，开发完成国际疾病分类第十次修订本(ICD-10) 北京临床版。这个规范标准在北京地区二级以上医院成功应用两年，成功支持北京地区诊断相关组 (DRGs)应用，能够支持传统疾病分类工作，可提高编码精度，满足了新的更高的信息处理要求。 ICD-10临床版； 诊断名称； 医学术语； 结构化设计 The design and implementation of the tenth revision of the International Classification of Disease Clinical Modification of Beijing HUANG FengCHEN Jian-mingGUO Mo-ningZHANG Xiu-meiHU Mu Department of Medical Record and Statistics, Peking University People s Hospital, Beijing 100044, China [Abstract] With building up a clinical modification system model by upgrading the standard disease classification system architecture, to collect those huge amount of diagnosis names and codes in use, based on the model to screen and coordinate the relation of them, the tenth revision of the International Classification of Disease Clinical Modification of Beijing is implemented.This standard has been successfully applied for two years in all those secondary and above level hospitals in Beijing. It could well support the work of deploying Diagnosis Related Groups in Beijing and support not only those traditional applications of disease classification but also those new and advance requirements of information processing. ICD-10CM; Clinical modification; Diagnosis name; Medical term 10. 3760/cma. j. issn. 1000-6672. 2011. 11. 009 基金项目：北京大学医学部“985工程”二期建设项目 (985205939) 作者单位：北京大学人民医院病案统计室（黄锋）；北京大学第 三医院（陈剑铭、胡牧）；北京市公共卫生信息中心（郭默宁、张修梅） ·836· （二）北京临床 @@[1]董景五.疾病和有关健康问题的国际统计分类第十次修订本 [M].第二卷.北京：人民卫生出版社，2008. @@[2] Centers for Disease Control and Prevention. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) [EB/OL]. [2009-09-15]. http://www. cdc. gov/ nchs/icd/icd9cm. htm. @@[3] National Center for Classification in Health, ICD10-AM[EB/OL]. [2009-09-15]. ht