产科ICD疑难编码处理技巧的探讨  

A Discussion on the Technique to Deal with the Difficult Codes of Obstetrics in ICD

作　　者：李东敏[1] 梁耀[1] 

机构地区：[1]广东医学院附属医院病案科,湛江市524001

出　　处：《中国病案》2008年第5期32-33,共2页Chinese Medical Record

基　　金：湛江市科技攻关项目[2005-19]

摘　　要：目的了解产科ICD疑难编码的成因并探讨解决对策。方法收集2004年1月1日至2007年6月30日的产科ICD疑难编码,逐一进行分析归类,提出处理的方法及技巧。结果共收集产科疑难编码316例,由于并发症复杂造成编码困难的113例,受产程、时间及母子关系影响的疑难编码41例,临床资料不足造成编码困难的83例,临床诊断与ICD不一致导致的编码困难60例,其他原因19例。结论深入分析疑难编码的原因,是有效解决ICD编码的关键。Objective To find out the causes of the difficult codes in obstetrics in ICD - 10 and explore the solutions. Methods Collect the difficult codes in obstetrics in ICD - 10 from January 1st in 2004 to June 30th in 2007 and analyze them one by one, then classify them by the causes. Results e aggregately collected 236 difficul.t codes in obstetrics： 83 of them were caused by complex complication; 113 by influence of labor, time or relationship bet weell the mother and infant; 83 by the lack of clinical materials; 60 by the discrepancy bet ween clinical diagnosis; and 7 by other causes. Conclusion It is the key point to analyze thoroughly the causes of the difficult codes.

关 键 词：ICD-10 疑难编码 产科 

分 类 号：R197.3[医药卫生—卫生事业管理]