ICD-10编码在先天畸形疾病分类中的扩展研究  

Encoded in Congenital Malformations in the Expansion of ICD-10

作　　者：李丽静[1] 韩晶[2] 索冠伟[3] 米丽艳[1] 赖德江[1] 

机构地区：[1]天津市儿童医院,天津300074 [2]天津市第一中心医院,天津300074 [3]天津医科大学第二医院,天津300074

出　　处：《中国卫生质量管理》2011年第5期52-55,共4页Chinese Health Quality Management

基　　金：天津市局级科研课题(2008-X-01)

摘　　要：目的解决ICD-10疾病分类中先天畸形未收录的疾病名称和临床诊断无对应编码的问题。方法汇总天津市儿童医院1998年1月～2008年1月诊治的所有先天畸形疾病诊断和临床需求1 043条,按照ICD-10疾病分类思想、分类原则和编码查找方法,应用扩展码编码具体操作程序确定对应编码。结果研究解决的编码分为3种:可确定编码、新增扩展码、补充扩展码,建立了先天畸形疾病编码和扩展编码字典库。结论完善先天畸形疾病分类中医学信息代码的规范模式,可减少误码率,规范临床诊断,有利于病历档案信息资源的开发与利用。Objective To solve the non - coding problems for clinicians in congenital malformations in the growing field of medicine and surgery clinics using ICD - 10 classification of diseases. Method From January 1998 to January 2008, the 1043 of congenital malformation disease diagnosis and clinical needs were collected from Tianjin Childreng Hospital. According to subject in classification of diseases, principles of classification and coding methods of ICD - 10, application of specific procedures exten- sion coding was used to identify the corresponding coding. Result The solved code can be divided into three kinds ： ＂ existed en- coding＂, ＂adding extension code＂ and ＂supplementary extended code＂, which provided coding and scalable coding dictiona~ li- brary for congenital malformations diseases. Conclusion Improvement of regulation medical information code for congenital mal- formation diseases can reduce error rates, standardize clinical diagnosis and help development and utilization information resources of medical records.

关 键 词：先天畸形 ICD-10 扩展 编码 

分 类 号：R197.323[医药卫生—卫生事业管理]