Mogli G D
Ministry of Health, Sultanate of Oman.
IHRIM. 1997 Nov;38(4):28-32.
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.
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。