丰富的病案资料利用计算机管理为医院临床供了大量的科研病案,已经成为医院科研最重要财富。在日常为临床进行病案检索,发现临床诊断与病案编码之间存在一些问题,影响病案检索的质量。产生问题原因如下:1临床医生诊断书写与疾病编码差距目前临床医师对国际疾病分类和卫生部填写 Rich medical records for the use of computer management for the clinical hospital for a large number of medical records, hospital research has become the most important asset. In the daily clinical case retrieval, found that there are some problems between clinical diagnosis and medical record coding, affecting the quality of medical record retrieval. Cause of the problem are as follows: 1 Clinicians write diagnosis and disease coding gap At present, clinicians fill in the International Classification of Diseases and the Ministry of Health