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一、存在的问题 (一)诊断名称书写不规范、不符合ICD要求:多数医师习惯于传统方式书写疾病诊断,与ICD分类对诊断书写要求不尽相同。医师们不了解ICD分类原则,例如“某某术后”、“某某息肉摘除术”、“颅脑外伤”、“老年性哆嗦症”等做为疾病诊断。“某某术手”既可是手术后的放疗或化疗,又可以理解为外科手术史或手术后的残存状态;“某息肉摘除术”应该是手术操作名称而不能做为疾病诊断;“颅脑外伤”分不清是皮外伤还是颅骨骨折,是脑震荡抑或脑挫伤,是开放性还是闭合性损伤;临床根本不存在“老年性哆嗦症”这一诊断术语。
First, the existing problems (A) the name of the diagnosis is not standardized, does not meet the ICD requirements: Most physicians are accustomed to the traditional way of writing disease diagnosis, and ICD classification of diagnostic writing requirements are not the same. Physicians do not understand the principle of ICD classification, such as “certain postoperative,” “certain polyp removal,” “traumatic brain injury,” “senile shivering,” and the like as a disease diagnosis. “Certain technique hand” can be either postoperative radiotherapy or chemotherapy, but also can be interpreted as the history of surgery or postoperative residual state; “a polyp removal surgery” should be the name of the operation can not be used as a disease diagnosis; “brain Trauma ”can not distinguish between skin trauma or skull fracture, concussion or brain contusion, is open or closed injury; clinical does not exist,“ senile shivering disease, ”the diagnosis term.