According to the ICD-10 dictionary in our hospital used at present can't meet the demand of clinicians writing diagnosis's request, exploring the establishment of clinical diagnosis dictionary database based on ICD-10, by col ecting each clinical department's common diagnosis names, matching each diagnosis and ICD-10 code, and by adding "left remarks", "right remarks" to ensure the clinical diagnosis of rigor, to achieve the basic clinical diagnosis is accurate, the disease coding only purpose. To ensure the diagnosis has the only cor ect code. To ensure the accuracy of date , and lay the foundation for the implementation of the DRGs.%针对ICD-10字典库无法满足临床医生书写诊断需求的问题,探讨基于ICD-10的临床诊断字典库的建立,通过搜集各临床科室常用疾病诊断名称,完成临床诊断与ICD-10编码的匹配,并通过添加"左备注"、"右备注"的形式确保临床诊断的严谨性,达到临床诊断基本有准确、唯一的疾病编码的目的。从而保证数据采集准确性,为DRGs的顺利实施奠定基础。
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