Trough the practice experience of implementing digitalization to papermade medical record,this paper sets forth the relationship among management mode of digitalization medical record,electronic medical record and paper-made medical record.It puts forward the solution to problems about light influence,slow rate of progress,inconsistent of image classification and software failure in medical record digitalization.It links traditional paper-made medical record management,emerging electronic medical record management and remote medical together.

国际疾病分类(ICD-10)是一门专业性高,实际操作性强的工作。加强医院病案管理,普及国际疾病分类知识,进一步提高临床医务人员对疾病分类的认识,使医院的病案资料更具科学性、准确性和实用性,充分发挥国际疾病分类在医疗、教学、科研、医院经营管理服务中的重要作用。结合疾病分类编码中存在的突出问题,对我院2004年～2006年恶性肿瘤住院患者的住院信息和疾病分类进行了统计分析。