基于ICD-10的结构化诊断系统对肿瘤疾病诊断的规范作用

中华养生保健 ›› 2023, Vol. 41 ›› Issue (24): 160-163.

基于ICD-10的结构化诊断系统对肿瘤疾病诊断的规范作用

姜星火¹, 徐凯^1,*, 马朝群¹, 史海波¹, 刘成洲², 王凌芳³

1.江苏省中医院医务处,江苏南京,210029;
2.山东省临朐县人民医院脊柱骨科,山东潍坊,262600;
3.山东省临朐县人民医院病案管理科,山东潍坊,262600

出版日期:2023-12-16 发布日期:2023-12-07
通讯作者: ^*徐凯,E-mail：xukai2322@126.com。
作者简介:姜星火（1964—）,女,汉族,籍贯：山东省烟台市,本科,主任中医师,研究方向：病案质控、病案管理。
基金资助:
江苏省医院协会医院管理创新研究课题（JSYGY-1-2019-19）

The Normative Role of ICD-10-based Structured Diagnosis System in the Diagnosis of Tumor Disease

JIANG Xing-huo¹, XU Kai^1,*, MA Chao-qun¹, SHI Hai-bo¹, LIU Cheng-zhou², WANG Ling-fang³

1. Medical Department of Jiangsu Provincial Hospital of Traditional Chinese Medicine, Nanjing Jiangsu 210029, China;
2. Department of Spinal Orthopedics, People's Hospital of Linqu County, Shandong Province, Weifang Shandong 262600, China;
3. Medical Record Management Department of Linqu County People's Hospital, Weifang Shandong 262600, China

Online:2023-12-16 Published:2023-12-07

摘要/Abstract

摘要： 目的评价结构化诊断系统对肿瘤疾病诊断的规范作用,以期为后续系统完善及临床应用提供借鉴与指导。方法采用文献综述、案例分析和对照研究的方法,阐述结构化诊断系统生成规范诊疗名称和编码的标准来源和过程,通过使用结构化诊断系统前后肿瘤诊断名称规范化改变的案例,以及对照研究中诊断名称规范率的变化,陈述结构化诊断系统对肿瘤疾病诊断的规范作用。结果自2017年结构化诊断系统上线后,病历首页的肿瘤主诊断规范率在试运行的科室中平均提高96%。通过χ²检验的推断统计,诊断名称规范率在使用和未使用该系统的科室中存在差异,差异有统计学意义（P<0.05）,结构化诊断系统的应用能够有效地提高肿瘤疾病诊断的规范率。结论结构化诊断系统对于医疗机构的肿瘤疾病诊断规范化具有重要意义,对于病案管理及质量控制提供了较大的帮助。

关键词: ICD-10, 疾病诊断, 结构化系统

Abstract: Objective To evaluate the normative role of structured diagnosis system in the diagnosis of tumor disease, in order to provide reference and guidance for the subsequent improvement and promotion of the system. Methods Using the methods of literature review, case analysis and comparative study, the source and process of standardized diagnosis and treatment names and codes generated by the structured diagnosis system were expounded. Changes in the name standardization rate (the number of correctly standardized main diagnosis names on the first page of the medical record divided by the total number of samples), stating the standardization effect of the structured diagnostic system on the diagnosis of tumor diseases. Results Since the launch of the structured diagnosis system in 2017, the standardization rate of the main tumor diagnosis on the page of medical records has increased by an average of 96 % in the trial operation departments. Through the inferred statistics of the Chi-square test, there is a statistically significant difference in the standardization rate of diagnostic names between departments that use and do not use the system (P<0.05), and the application of the structured diagnosis system can effectively improve the standardization of tumor diagnosis rate. Conclusion The structured diagnosis system is of great significance to the standardization of diagnosis in medical institutions, and provides great help for medical record management and quality.

Key words: ICD-10, disease diagnosis, structured system

中图分类号:

R197.3

姜星火, 徐凯, 马朝群, 史海波, 刘成洲, 王凌芳. 基于ICD-10的结构化诊断系统对肿瘤疾病诊断的规范作用[J]. 中华养生保健, 2023, 41(24): 160-163.

JIANG Xing-huo, XU Kai, MA Chao-qun, SHI Hai-bo, LIU Cheng-zhou, WANG Ling-fang. The Normative Role of ICD-10-based Structured Diagnosis System in the Diagnosis of Tumor Disease[J]. ZHONGHUA YANGSHENG BAOJIAN, 2023, 41(24): 160-163.

参考文献

[1] BRIGHT B, K E P, MAHA R. Utilization of EPIC Electronic Medical Records System for a Limb Salvage Quality Improvement Initiative[J]. Journal of Vascular Surgery,2023,77(4):375.
[2] YILMA T M, TILAHUN B, MAMUYE A, et al.Organizational and health professional readiness for the implementation of electronic medical record system: an implication for the current EMR implementation in northwest Ethiopia[J]. BMJ Health Care Inform,2023,30(1):e100723.
[3] 吕国友,何月枝,郑美莲,等. ICD-10编码检索系统研发应用[J].中国医院统计,2019,26(5): 394-396.
[4] 郭果桃. ICD-10编码准确性的影响因素及改进措[J].基层医学论坛,2021,25(14):2052-2053.
[5] 周艾婧,邓川燕,张义锣.肿瘤疾病的ICD-10编码[J].中国病案,2020,21(5):28-31.
[6] 中华人民共和国卫生健康委员会.原发性肺癌诊疗指南(2022年版)[J].中国合理用药探索,2022,19(9):1-28.
[7] 吕祎然,刘婕,郝舒欣,等.医院就诊数据疾病诊断自动编码和分类统计工具的建立与评价[J].实用预防医学,2019,26(5):630-634.
[8] 江惠婷,杨延斌.关于提高ICD-10编码准确性的探讨[J].办公室业务,2020(14):47-48.
[9] 邓汝松,姚小红,隆霜,等.胶质瘤结构化病理报告系统的建立及临床应用[J].临床与实验病理学杂志,2023,39(3):271-275.
[10] 孙凤英,于修义.基于胸外科结构化电子病历的人工智能诊断系统构建实践[J].中国数字医学,2018,13(11):29-31.
[11] KIM S, HOCH M J, COOPER M E, et al.Using a Website to Teach a Structured Reporting System, the Brain Tumor Reporting and Data System (BT-RADS)[J]. Current Problems in Diagnostic Radiology, 2020, 50(3):25-30.
[12] FATIMA R, ELLEN C, ALAN H, et al.TP8.1.7 The utility of a timeline and episode structured breast cancer data system to study outcomes following neoadjuvant chemotherapy for cases stratified by HER2 status[J]. British Journal of Surgery, 2021,4(11):7-11.
[13] POULTER S, STEER B, BAGULEY B.Comparison of the glim, espen and icd-10 criteria to diagnose malnutrition and predict post-hospital discharge outcomes: an observational study in an oncology population[J]. Clinical Nutrition ESPEN,2021,46:5569.
[14] POULTER S, STEER B, BAGULEY B, et al.Comparison of the GLIM, ESPEN and ICD-10 Criteria to Diagnose Malnutrition and Predict 30-Day Outcomes: An Observational Study in an Oncology Population[J]. Nutrients,2021,13(8):2602.
[15] 鲁杨,任永松,隗和红,等.关于ICD-10分类结构的理论探讨[J].中国卫生统计,2021,38(5):788-789.
[16] 钱翊. 骨恶性肿瘤ICD-10编码相关问题的探讨[J].中国病案,2021,22(6):37-38.
[17] 严惠莲,廖定轲,王洁容,等.ICD-10肿瘤编码准确性影响因素和解决对策[J].中国医药科学,2019,9(20):245-247.
[18] 王晶晶,赵慧智,王卫卫,等.诊断-编码映射模式在肿瘤专业病案编码工作中的应用效果[J].中国病案,2023,24(2):10-12.
[19] 张艺,滕飞,胡节.基于多任务学习的国际疾病分类自动编码模型[J].广西科学,2023,30(1):114-120.
[20] 王芳. 病案信息技术对病案室编码及病案质量的影响[J].中国卫生标准管理,2023,14(3):10-13.
[21] 李磊,时涛.DRG支付背景下山东省55家三级综合医院住院医疗服务评价研究[J].中国医院管理,2023,43(5):27-30.
[22] 曾旖旎,姚岚,杨爱平.DRG/DIP支付方式改革背景下山东省三级公立医院薪酬满意度及影响因素研究[J].中国医院,2023,27(5):21-24.
[23] 王璐瑶. 医院DRG成本管控体系的应用研究[J].行政事业资产与财务,2023(8):62-65.