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目的通过调查临床医师使用疾病字典库的情况,探讨提高临床医师使用疾病分类字典库的方法。方法对2013年3月份2987份电子病案首页中的“出院主要诊断”进行全样本调查,同时,采用随机抽样方法对78位临床医师开展问卷调查并进行统计。结果在2987份病案首页的“出院主要诊断”调查中,只有9.9%的主要诊断使用了疾病分类字典库,医师不使用字典库的主要原因中字典库名称不全或有误占53.9%,系统操作不方便占43.4%,操作不熟练占28.9%。结论加强疾病分类知识培训、规范临床诊断名称、完善字典库和系统操作方法是提高疾病分类字典库使用效率的主要方法。
Objective To explore ways to improve the use of disease classification dictionaries by clinicians by investigating the use of disease dictionary by clinicians. Methods A full sample survey was conducted on the “main diagnosis of discharge” of 2987 electronic medical records in the first page of March 2013. At the same time, 78 clinicians were surveyed and statistically analyzed by random sampling method. Results Of the 2987 primary medical records of discharge, only 9.9% of the major diagnoses used the disease classification dictionary, and 53.9% of the primary reasons that the physicians did not use the dictionary were incomplete or incorrect, 43.4% inconvenient system operation, unskilled operation accounted for 28.9%. Conclusion Strengthening the training of disease classification knowledge, standardizing the names of clinical diagnosis, improving the dictionary database and system operation method are the main methods to improve the efficiency of using the disease dictionary.