烧伤后残余创面相关编码分析  

Coding Analysis of Residual Wound after Burn

作　　者：展丽潇 史文峰 蒋昆 王克甲 Zhan Lixiao;Shi Wenfeng;Jiang Kun;Wang Kejia(Department of Information,The First Affiliated Hospital of Military Medical University of PLA Air Force,Xi'an 710032,Shanxi Province,China;不详)

机构地区：[1]空军军医大学第一附属医院,陕西省西安市710032

出　　处：《中国病案》2020年第5期31-33,共3页Chinese Medical Record

基　　金：陕西省创新能力支撑计划项目(2018KRM101)。

摘　　要：烧伤后残余创面是烧伤科常见的疾病诊断。编码员对于残余创面的概念不清,编码难度较大。本文总结对于疾病编码,可分为手术相关性和非手术相关性2种情况,手术相关性残余创面分类于手术后并发症T81.-,非手术相关性残余创面的分类主要体现残余创面的临床表现,如烧伤后慢性溃疡、烧伤后创面感染;手术编码需根据不同的手术方式及部位进行分类,主要有清创术、皮肤移植术(游离皮片移植术86.60-86.69、皮瓣移植术86.70-86.75)、VSD引流术等。编码时,需明确疾病类型与手术方式,再给予正确分类和编码。Residual wound after burn is a common diagnosis in burn depa-rtment.The coders are not clear about the concept of residual wound surface,so it is difficult to code.This paper summarized the disease codes,which can be divided into two types:surgical correlation and non-surgical correlation.Surgical correlation residual wounds were classified as postoperative complications T81.-,the classification of non-surgical related residual wounds mainly reflects the clinical manifestations of residual wounds,such as post-burn chronic ulcers and post-burn wound infection;Surgical codes need to be classified according to different surgical methods and sites,mainly including debridement,skin transplantation(86.60-86.69 for free skin transplantation,86.70-86.75 for flap transplantation),and VSD drainage.When coding,the disease type and surgical method should be identified,and then the correct classification and coding should be given.

关 键 词：烧伤 残余创面 编码 

分 类 号：R644[医药卫生—外科学] R197.323[医药卫生—临床医学]