Suppr超能文献

《国际疾病分类》在病历管理中的作用。

Role of International Classification of Diseases in medical record management.

作者信息

Mogli G D

机构信息

Ministry of Health, Sultanate of Oman.

出版信息

IHRIM. 1997 Nov;38(4):28-32.

Abstract

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.

摘要

病历是健康信息的主要来源。因此,有必要按照世界卫生组织发布的《国际疾病分类》中规定的指南,通过记录所有所需信息来保持良好的患者记录,例如病史、体格检查、病程记录、检查、治疗(包括外科手术)、完整诊断和最终结果等。如果记录准确完整,那么医疗保健信息就可以根据世界卫生组织发布的《国际疾病分类》准确完整地获取和分类。因此,《国际疾病分类》在管理良好的病历方面发挥着重要作用。

相似文献

3
Medical documentation and record management in Germany.
J Am Med Rec Assoc. 1991 Oct;62(10):28-30.

文献检索

告别复杂PubMed语法,用中文像聊天一样搜索,搜遍4000万医学文献。AI智能推荐,让科研检索更轻松。

立即免费搜索

文件翻译

保留排版,准确专业,支持PDF/Word/PPT等文件格式,支持 12+语言互译。

免费翻译文档

深度研究

AI帮你快速写综述,25分钟生成高质量综述,智能提取关键信息,辅助科研写作。

立即免费体验