Zhongguo quanke yixue (Nov 2023)
Development of General Practice Diagnostic Terminology and Coding and Empirical Study on Its Application
Abstract
Background Establishing a unified set of diagnostic terms and codes for general practice is an important means to improve the service level of community health service institutions and promote the construction of general practice system in China. Establishing a unified set of diagnostic terms and codes of general practice is an important way to improve the service level of community health service institutions and the construction of general practice system in China. However, there has been a lack of standardized diagnostic terms and codes suitable for the development situation of general practice in China, leading to non-standard diagnosis of general practitioners, which has seriously hindered the development of general practice in China. Objective To construct a set of diagnostic terms and codes for general practice in community health care service, and validate its efficiency, so as to promote the standardization of community general practice diagnosis. Methods A set of diagnostic terms and codes for general practice suitable for community health care service was constructed based on ICD-10 by using literature research and expert consultation, combined with the spectrum of common health problems and diseases in the community, and piloted in 259 community health service centers in two administrative districts of Shenzhen from September 2021 to February 2022 to conduct an empirical study. The pilot implementation was analyzed to verify the rationality and validity of the diagnostic terms and codes set by using the background diagnostic data of the community health service information system and questionnaire study with a sample of community general practitioners as the basic data. Results A set of diagnostic terms and codes for general practice was completed, including 41 general practice diagnostic categories, involving 6 629 standardized diagnostic terms and codes for general practice. The pilot results of the two districts in Shenzhen indicate that the composition of standardized diagnostic names in the standardized intervention areas was 86.13% to 95.38% higher than the non-pilot areas. The number of diagnostic names involved in this period in the pilot area decreased by 96.60% year-on-year. The standardized intervention resulted in a significant focus on common diagnoses in general practice, which is basically consistent with the disease spectrum in the community, with a high degree of clustering of common disease diagnoses in the community. The results of the questionnaire survey showed that 87.31% (227/260) of the survey respondents believed that the code set can promote the standardization of community diagnosis, and 77.31% (201/260) of the respondents supported the online application of the code set. Conclusion The research has preliminarily established a standardized set of diagnostic terms and codes for general practice, forming a community general practice diagnostic term dictionary to solve the problem of polysemy in data analysis, while taking into account upward and downward referrals and medical insurance dockin, which has effectively improved the efficiency and standardization of community diagnosis and treatment, and played a positive role in promoting the development of primary health services.
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