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  [摘要] 目的 规范病案首页中疾病诊断的书写，使疾病诊断的书写更加科学化、标准化和规范化，促进医院信息化的建设。 方法 将ICD码字典库嵌入医院HIS系统中医生工作站的电子病历模块中，采用ICD-10疾病诊断规范病案疾病诊断书写，不断补充完善ICD码字典库。 结果 我院病案的疾病诊断名称更加规范、统一，为病案首页提供更加完善、可靠的基本数据内容，实现网络信息数据共享。 结论 病案疾病诊断的书写使用国际疾病分类的疾病诊断能够提高医院的信息化程度，加速数字化医院建设的步伐。

 [关键词] 国际疾病分类；疾病诊断；ICD码字典库；系统

 [中图分类号] R197 [文献标识码] B [文章编号] 1673-7210(2012)02(c)-0156-02

 Application of international classification of diseases to the diagnosis in medical record

 YUN Fengyu

 Department of Information, the First People's Hospital of Huizhou City, Guangdong Province, Huizhou 516003, China

 [Abstract] Objective To standardize the diagnosis of disease in the first page of medical record, and to make the diagnosis more scientification, standardization and regularization, and to promote the construction of hospital information. Methods international classification of diseases (ICD) code dictionary library was embedded in the electronic medical workstation record modules of the hospital information system (HIS), ICD-10 diagnostic criterion was used for writing disease diagnosis in medical record, and ICD code dictionary library was supplied continuously. Results The diagnosis of diseases in my hospital medical record was more standardized and uniformed, which provided more impeccable and reliable basic data contents to the first page of medical record, and realized the information and data sharing in the network. Conclusion Application of international classification of diseases to the diagnosis in medical record can improve the level of the hospital information, and accelerate the construction of the digital hospital.

 [Key words] International classification of diseases; Disease diagnosis; ICD code dictionary library; System

 长期以来，临床医生的疾病诊断书写没有统一的、标准的疾病诊断书写规范，临床医生的诊断术语往往是根据教科书或临床书写经验而来，每间医院、每个医生对同一疾病诊断的书写都有差别[1]，为规范病案首页中疾病诊断的书写，使疾病诊断的书写更加科学化、标准化和规范化，促进医院信息化的建设，我院在医院HIS系统中引入国际疾病分类(international classification of diseases，ICD)的使用，开发了医生工作站ICD编码使用系统，在医生工作站上引导医生在书写疾病诊断时，使用国际疾病分类的疾病名称进行书写。

 1 国际疾病分类的概念[2]

 国际疾病分类(international classification of diseases)简称ICD，是目前国际上共同使用的统一的疾病分类方法，自产生到现在已有一百多年的历史，它在世界卫生组织和各成员国的关注和支持下得以不断地补充、完善，并成为国际公认的卫生信息标准分类。世界卫生组织疾病分类合作中心负责进行国际疾病分类的修订、推广和应用工作 ......