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Research on the establishment and application of clinical diagnostic coding score database based on electronic medical records |
WENG Zhi-xiong1 YU Zhi-jin2 LIN Yan-feng3 LI Shao-ling4 PENG Cheng-yuan5 ZHOU HUA-jian5 CHEN Hui-xin2 YU Rong1▲ |
1. Department of Medical Quality Control and Management, Huizhou Central People′s Hospital, Guangdong Province,Huizhou 516001, China;
2. Department of Gastroenterology, Huizhou Central People′s Hospital, Guangdong Province,Huizhou 516001, China;
3. Department of Medical Insurance Management, Huizhou Central People′s Hospital, Guangdong Province, Huizhou 516001, China;
4. Medical records Statistics Office, Huizhou Central People′s Hospital,Guangdong Province, Huizhou 516001, China;
5. Department of Information, Huizhou Central People′s Hospital of Guangdong Province, Huizhou 516001, China |
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Abstract Based on the structured electronic medical record system of a top three general hospital in Huizhou City,Guangdong Province,the three libraries of"clinical disease diagnosis database that conforms to the logical thinking of doctors","ICD-10 disease diagnosis coding library" and "medical insurance disease score database" are combined into one. In order to standardize and unify the doctor′s disease diagnosis terminology, optimize the work flow of medical record coding personnel, prompt medical personnel to make reasonable diagnosis and treatment, and strictly control the unreasonable growth of medical expenses, with a view to satisfying hospital medical quality management, medical record information management, medical insurance payment, medical research The development needs of various aspects such as teaching provide a reference plan for the next implementation of disease diagnosis-related classification in Huizhou.
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