以两个或以上人名命名的综合征ICD-10编码探讨  

Discussion on ICD-10 Coding of Syndromes Named after Two or More Personal Names

作　　者：何凯平[1] 张柔玲[1] 方浩[2] 庞婷婷[2] 

机构地区：[1]广东药学院附属第一医院病案管理科,广州市510080 [2]中山大学中山眼科中心病案统计科,广州市510060

出　　处：《中国病案》2014年第8期24-25,共2页Chinese Medical Record

摘　　要：以两个或以上人名命名的综合征(病),在编码工作中经常会遇到,编码员对这类综合征(病)名称的发展由来如果了解得不够深入,易导致编码错误。综合征编码原则:不含人名地名时,以"综合征"、"病"、"疾患"或疾病全称作为主导词查找;含人名地名时,直接以人名地名为主导词查找。本文通过对Axenfeld-Rieger综合征、Vogt小柳-原田综合征两例编码的分析,探讨以两个或以上人名命名的综合征(病)编码的方法及注意事项,以便协助编码人员在面对此类问题时更好更准确地进行编码工作,以提高该类疾病分类的准确率,并通过进一步分析国际疾病分类需求与实际编码操作产生的矛盾,对如何更好地实现病案编码理论与实际相结合提出建议。Coders usually encounter syndrome named after two or more names in our coding work. But they often make mistakes in the ICD-10 coding of it in case of inadequate understanding of its name＇ s origin. The coding rules of syndrome is： when the syndrome doesn＇t contain name, we use＂syndrome＂, ＂disease＂, ＂disorder＂ or the full name of the disease as the leading word; when containing name, use the name as the leading word. Through the analysis on Axenfeld-Rieger syndrome and Vogt-Koyanagi-Harada syndrome, this paper discusses the coding method and announcements of syndrome named after two or more names, in order to better assist coders to encode accurately in the face of such problems. The futher analysis on the contradiction between ICD theoretical requirements and the coding practice, can make good recommendations on how to achieve perfect combination of coding theory and practice.

关 键 词：人名命名 综合征 ICD-10编码 

分 类 号：R197.323[医药卫生—卫生事业管理]