3种疑难疾病的ICD-10编码浅析  

An Analysis of ICD-10 Coding for Three Challenging Diseases

作　　者：宋艳红[1] 王莉[1] 

机构地区：[1]武汉科技大学附属天佑医院,湖北武汉430064

出　　处：《现代医院》2017年第11期1640-1642,共3页Modern Hospitals

摘　　要：目的探讨如何正确应用ICD-10,提高疑难疾病编码的准确性。方法对3例疑难疾病的相关资料进行阅读、分析,并与临床医师、病理科医师沟通,充分理解疾病的内涵,变换合适的主导词,再应用ICD-10编码规则进行疾病分类。结果对疑难疾病编码要根据疾病的主要病因、病理、临床表现和解剖部位等特征通过变换主导词进行ICD-10编码。结论 ICD-10是一门具有一定技术难度和复杂性的专门学科,只有掌握ICD-10编码规则,具备一定的医学知识和外语知识,具有高度责任心,通过阅读病案并与临床、病理科医师有效沟通,才能提高ICD编码的准确性。Objective To explore how to apply ICD-10 correctly to improve the accuracy of the coding of challenging diseases. Methods We reviewed and analyzed the relevant data of 3 challenging cases,communicated with clinicians and pathologists,fully understood the connotation of diseases,changed a proper main word,and then classified diseases by ICD-10 coding rule. Results The ICD-10 coding was carried out by changing the main word based on main cause,pathology,clinical manifestation and anatomical site of diseases. Conclusion ICD-10 is a specialized subject containing technical difficulty and complexity. The accuracy of ICD-10 coding can improve only when coders master ICD-10 coding rules,possess certain medical and foreign language knowledge,have a high sense of responsibility,review medical cases and effectively communicate with clinicians and pathologists.

关 键 词：ICD-10 主导词 疑难编码 

分 类 号：R197.323.1[医药卫生—卫生事业管理]