4例疑难编码的探讨  

Discussion of 4 Cases of Difficult Coding

作　　者：阿依努尔 热娜古丽.依布拉音 

机构地区：[1]新疆维吾尔自治区中医院病案室,乌鲁木齐市830000

出　　处：《中国病案》2012年第9期35-35,M0002,共2页Chinese Medical Record

摘　　要：灰皮病、毛周角化病、灰泥角化病和低顺应性膀胱的编码,其疑难主要因于疾病别名多、分类不一,主导词选定困难。选定主导词者,病历资料中有与疾病不完全一致影响进一步选择编码。通过与医师沟通解决分类疑虑;对分类不一者根据疾病的诊断依据选主导词。此外,查阅资料,了解疾病归属,扩充临床知识,结合正确的编码方法可解决疑难编码。Now there are 4 cases of difficult coding existing： ashy dermatosis, lichen priaris, stucco keratosis and low-compliance urinary. The dif- ficulty mainly comes from multi-alternative names, different classification, and how to select the leading words; for these diseases that have selected leading words, some information of the medical records is not completely consistent with the diagnosed disease, which obstructs following selection cod- ing. However, we can resolve the doubt on coding for the disease which classification not consistent and select the leading word according to diagnostic basis through communicating with clinicians. In addition, through looking up relevant materials, getting acquaint with the illness attribution, expand- ing clinical knowledge, combining with the correct encoding method, we can solve the knotty coding of these 4 cases.

关 键 词：ICD-10 疑难编码 主导词 

分 类 号：R197.3[医药卫生—卫生事业管理]