中医临床科研数据西医疾病诊断规范的研究分析-中国数字医学.PDFVIP

信息化论坛 Information Forum 中医临床科研数据 西医疾病诊断规范的研究分析 ① ＊ ② ① ② ③ 宋红梅 刘保延 张润顺 何丽云 宋观礼 周雪忠 摘 要 目的：通过西医疾病诊断与标准诊断的吻合程度比较，分析目前中医临床住院病历诊断的现状。方法：选取行业 专项参研单位所在的全国23家医院的34个临床科室电子病历采集数据中具有完整西医疾病诊断的数据，以国际疾病分类第 十次修订（ICD-10）为标准，在数据库中初步对原始诊断进行规范，通过语句建立比较，得出结论。结果：西医疾病诊 断和ICD-10的符合程度是36.57%。结论：针对符合率较低的情况，进一步加强临床医务人员对ICD-10的学习和熟悉是正 确书写病历西医诊断的前提。 关键词 中医临床科研数据　ICD-10 西医疾病诊断 Doi:10.3969/j.issn.1673-7571.2013.01.021 Research and Analysis of Western Medicine Clinical Diagnosis Standard of Clinical Research Data of Traditional Chinese Medicine / SONG Hong-mei, LIU Bao-yan, ZHANG Run-shun, et al//China Digital Medicine.-2013 8(1): 72 to 75 Abstract Objective: Through comparison of fitting of western medicine disease diagnosis and standard diagnosis, the current situation of clinical inpatient medical record diagnosis of traditional Chinese medicine is analyzed. Methods: Data with complete western medicine disease diagnosis in data collected from electronic medical records of 34 clinical divisions of 23 hospitals in China which are special research units in the industry is selected. The tenth revision of international classification of diseases (ICD-10) is used as the standard. In the database original diagnosis is preliminarily standardized. Through the statements the comparison is established and the conclusion is drawn. Results: the western medicine disease diagnosis and ICD-10 conform to the degree is 36.57%. Conclusion: In view of the low coincidence rate, further strengthening clinical medical staffs’ learning and understanding of ICD-10 is the premise of correct writing of medical records of western medicine diagnosis. Keywords clinical research d