Renner J H, Bauman E A
J Fam Pract. 1975 Aug;2(4):279-81.
The data found in medical records, particularly in problem-oriented records, could yield very useful information for many aspects of the health care delivery system. Unless the tools and methods used in the analysis of health care data are very carefully designed, the potential value of this information cannot be fully realized. Coding is a critical step in the process of converting medical record data into useful information. This paper presents six criteria as design goals for a standard, comprehensive, coherent set of nomenclatures, classifications, taxonomies, and corresponding coding schemes for the analysis of medical and administrative record data. These goals are: compatibility with established routine operating procedure, health care problem specificity, hierarchical structure, economy through articulation of the components with one another and through the similarities in various aspects of health care delivery, and adaptability to change.
病历中发现的数据,尤其是问题导向型病历中的数据,可为医疗服务提供系统的许多方面提供非常有用的信息。除非用于分析医疗数据的工具和方法经过精心设计,否则这些信息的潜在价值无法得到充分实现。编码是将病历数据转化为有用信息过程中的关键一步。本文提出了六项标准,作为一套标准、全面、连贯的术语表、分类法、分类体系以及用于分析医疗和行政记录数据的相应编码方案的设计目标。这些目标是:与既定的常规操作程序兼容、医疗问题特异性、层次结构、通过各组成部分之间的清晰表述以及医疗服务各方面的相似性实现经济性,以及适应变化。