女性泌尿生殖系统损伤的编码探讨  

Coding Investigation of Female Urogenital System Injury

作　　者：刘锐[1] 朱伦锋[1] 赖伏虎[2] 钟春阳[1] 高茜雯[1] 康辉蓉 

机构地区：[1]赣州市人民医院,赣州市341000 [2]深圳市第八人民医院信息统计科,深圳市518100

出　　处：《中国病案》2014年第5期30-32,共3页Chinese Medical Record

摘　　要：探讨女性泌尿生殖系统损伤疾病和手术编码的分类及查找方法。女性泌尿生殖系统损伤发生部位多为阴道、子宫、外阴、会阴、膀胱、尿道,临床上这些部位的裂伤又分为暴力性裂伤和手术操作后的并发症两大类。暴力性裂伤又可分为产褥期伤、陈旧性产伤和外伤,损伤性质不同,疾病和手术编码亦不同。影响女性泌尿生殖系统损伤编码的因素包括疾病部位、损伤的原因。临床医师容易忽略损伤的原因,编码员如果再疏忽就容易导致编码错误。了解疾病分类的编码规则,认真阅读病案,区分损伤性质,损伤时间及部位,是避免错误编码的根本。To investigate the classification and search method of female urogenital system injury and operation coding.Female urogenital system injury mostly occurred at vagina,uterus,vulva,perineum,bladder and urethra,these injuries were divided into two categories named violent laceration and complications after operation in clinic.Violent laceration was also divided into puerperal wounds,old birth injury and trauma.The diseases and operation coding were different according to the character of injuries.The factors that effected the coding of female urogenital system injury included diseases position and the reasons of trauma,and the ignorance on the reasons of trauma of the coders and clinicians would resulted in coding errors.Therefore,to understand the classification rules of diseases and reading medical records carefully should be fundamental to avoid coding errors.

关 键 词：泌尿生殖系统 损伤 手术 编码 女性 

分 类 号：R711[医药卫生—妇产科学]