先天性畸形、变形和染色体异常疾病编码疑难解析  

RESOLUTION OF THE DISEASE CODING DIFFICULTY FOR CONGENITAL MALFORMATION,TRANSFIGURATION AND CHROMOSOME ABNORMITY

作　　者：杨丰[1] 梁耀[1] 

机构地区：[1]广东医学院附属医院,广东广州524001

出　　处：《现代医院》2010年第2期135-136,共2页Modern Hospitals

摘　　要：目的为提高先天性畸形、变形和染色体异常的疾病编码正确率及疾病的分类水平。方法以黑斑息肉病、茎突综合征、心肌桥为例,进行编码及分类过程的阐述。结果在先天性畸形、变形和染色体异常疾病的编码分类过程中,当疾病的名称和编码表中的病名不一致或不完全一致时,必须查阅病历,了解临床诊断的依据,同时,与临床知识及经验丰富的临床医生沟通,才能正确编码分类,否则,很难编码或编码错误,从而影响病案资料的查询和统计信息的真实性。结论要正确编码分类先天性畸形、变形和染色体异常的疾病,编码员必须有高度责任心,熟悉ICD的技术及疾病编码原则,编码前必须查阅相关病历资料,与主管临床医师充分交流。Objective To advance right rate of disease coding and level of disease assorting of congenital malformation, transfiguration and chromosome abnormity. Methods To expatiated coding and assorting course of Peutz-Jeghers Syndrome,Englesyndrome and Myocardialbridge. Results When the disease name is not or incompletly accord with the disease name of coding hst in the coding and assorting course of congenital malformation, transfiguration and chromosome abnormity,the coder must consult case history,and realize gist of clinical diagnostic,at the same time, to communicate with clinical doctor who has plenty clinical knowledge and experience, so that the coding and assorting win be right. Otherwise the coding is very difficult or incorrect. Thereby it will affect case history data query demanding and statistical reality. Conclusion If the coder want accurately cod and assort disease of congenital malformation, transfiguration and chromosome abnormity, he must has high responsibility, and be up on technique of ICD and disease code rule. He must consult case history data and fully communicate with clinical charge doctor before coding.

关 键 词：先天性疾病 国际疾病分类 编码 

分 类 号：R726.2[医药卫生—儿科] R596.1[医药卫生—临床医学]