Study on the standardization of diagnostic name of outpatient diseases
LI Jingnan1 DUAN Qingchuan2 ZHAO Jinshun1 LIU Jing1 CHEN Jianming1 XIA Zhiwei1▲
1.Department of Medical Record, Peking University Third Hospital, Beijing 100191, China;
2.Department of E.N.T., Peking University Third Hospital, Beijing 100191, China
Abstract：Objective To analyze the type of non-standard diagnosis writing of outpatient diseases, and to explore the effective measures for physicians' writing standards. Methods A retrospective study was conducted on the outpatient disease diagnosis writing in Peking University Third Hospital from September 2007 to March 2014. Results There were 4804 non-standard outpatient diagnosis writing. The types of non-standard diagnosis could be divided into abbreviated disease name (137 items), disease name written by English (99 items), non-standardized medical terms (2021 items), reversed the order of diagnostic name (24 items), undefined or too detailed diagnosis (1143 items), and written by non-classified anatomical site in ICD-10 (1380 items). Conclusion In view of the irregular type of diagnosis writing of outpatient diseases, the clinicians should be trained to standardize the clinical thinking habits, improve the classification of diseases and promote the support of health information development.
李婧楠1 段清川2 赵金顺1 刘晶1 陈剑铭1 夏志伟1▲. 门诊疾病诊断名称规范化研究[J]. 中国医药导报, 2017, 14(18): 64-67.
LI Jingnan1 DUAN Qingchuan2 ZHAO Jinshun1 LIU Jing1 CHEN Jianming1 XIA Zhiwei1▲. Study on the standardization of diagnostic name of outpatient diseases. 中国医药导报, 2017, 14(18): 64-67.
2017, Vol. 14 
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