探讨介入放射性技术的手术操作与编码  

A Discussion on the Surgery Operation and Encoding of Interventional Radiology Technology

作　　者：李建炜[1] 林洁中[1] 蔡玉桂[1] 陈小花[1] 张安[1] 陈娟[1] 

机构地区：[1]湛江中心人民医院,湛江市524037

出　　处：《中国病案》2012年第10期21-23,共3页Chinese Medical Record

摘　　要：我国的介入放射学始于20世纪80年代初,起步较晚,但进展迅速,尤其是介入治疗,可谓开创了微/少创诊疗的先河。在手术操作编码的工作中,如何对这一技术进行系统、正确的编码,是编码人员的新课题。因此,本文通过介绍介入放射性技术的有关内容,与同道商讨有关介入放射性技术的ICD-9-CM-3编码,达到提高编码质量的目的。使临床医师也要了解介入放射性技术的ICD-9-CM-3编码对病历书写内容的要求,医师书写手术名称应包括解剖部位+术式+目的 +器械(手法)+入路,尽可能详细、准确、完整;编码人员根据手术名称结合编码原则正确编码,以便提高编码的准确率。Objectives At the beginning of the 1980＇ s, Interventional Radiology was introduced in China, although it started a little late, it devel- oped rapidly. Since then, the minimal invasion therapy has been born. In the work of encoding of surgery operations, it is the new research project to the coders to encode this new technology systematical and correctly. Therefore, this essay is to improve the encoding quality by briefly introducing In- terventional Radiology Technology （LRT） and discussing the interrelated ICD-9-CM-3 codes. Result Allow surgeons to understand the required medical record contents of using ICD-9-CM-3 codes in LRT. The operation name should be presented as much detail, accurate and complete as possible： the anatomical site, procedures, resection rage, surgical instrument and well as approaches. Coders should increase the accuracy according to encoding prin- ciples combined with the surgery names.

关 键 词：介入放射性技术 手术病历书写 ICD-9-CM-3 

分 类 号：R197.3[医药卫生—卫生事业管理]