ZHONGHUA YANGSHENG BAOJIAN ›› 2023, Vol. 41 ›› Issue (24): 160-163.

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

JIANG Xing-huo1, XU Kai1,*, MA Chao-qun1, SHI Hai-bo1, LIU Cheng-zhou2, WANG Ling-fang3   

  1. 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

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

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