国际疾病分类在病案管理中的作用。

G D Mogli
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引用次数: 0

摘要

医疗记录是健康信息的主要来源。因此,有必要按照世界卫生组织出版的《国际疾病分类》的指引,保存良好的病人记录,记录所有必需的资料,例如病史、体格检查、进展记录、调查、治疗(包括外科手术)、完整的诊断和最终结果等。如果文件准确和完整,则可以根据世卫组织出版的《国际疾病分类》准确和完整地获得卫生保健信息并进行分类。因此,《国际疾病分类》在管理良好的医疗记录方面发挥着重要作用。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Role of International Classification of Diseases in medical record management.

The Medical Record is the major source of Health information. Therefore, it is necessary to maintain good patient records by documenting all the required information, e.g. history, physical examination, progress notes, investigations, treatment including surgical procedures, complete diagnosis and end result, etc., as per the guidelines stated in the International Classification of Diseases published by World Health Organisation. If the documentation is accurate and complete, the health care information could be obtained and classified accurately and completely according to International Classification of Diseases published by WHO. Hence, International Classification of Diseases plays an important role in managing good medical records.

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