Gibson K, Ives J, Wilson M, Richardson D
Princess Alexandria Hospital, Brisbane.
Health Inf Manag. 1996 Sep-Nov;26(3):141-4. doi: 10.1177/183335839602600314.
Clinical data for all current outpatients at a large tertiary hospital has been collected for analysis. Patient diagnoses for selected "key" clinics have been coded to ICD-9-CM standards. Methods to reduce the volume of coding required for such data collection are discussed, and include short-lists of codes, default assignment of diagnoses codes according to the nature of visit, and producing a "discharge" summary for outpatients, similar to that routinely produced for inpatients.
一家大型三级医院收集了所有当前门诊患者的临床数据用于分析。选定“关键”诊所的患者诊断已按照国际疾病分类第九版临床修订本(ICD - 9 - CM)标准进行编码。文中讨论了减少此类数据收集所需编码量的方法,包括编码短清单、根据就诊性质默认分配诊断编码,以及为门诊患者生成类似于常规为住院患者生成的“出院”总结。