踝骨骨折Lauge-Hansen分型编码分析  

Code analysis of Lauge-Hansen typing of ankle fracture

作　　者：刘吉羊 Liu Jiyang(Medical Record Statistics Management Department,Xiaogan Central Hospital,Xiaogan 432000,China)

机构地区：[1]孝感市中心医院病案统计管理科,湖北孝感432000

出　　处：《中国医院统计》2020年第6期564-567,共4页Chinese Journal of Hospital Statistics

摘　　要：目的踝骨骨折作为骨科临床的常见疾病,医师常用Lauge-Hansen标准对其分型、诊断和治疗。编码员应通过ICD-10建立起两者的对应关系。方法通过对踝骨解剖结构地了解,深入理解旋后-外旋型、旋前-外旋型、旋后-内收型、旋前-外展型和垂直压缩型等5种Lauge-Hansen分型,并利用ICD-10损伤编码原则逐个分析。结果旋后-外旋型、旋前-外旋型、旋后-内收型、旋前-外展型和垂直压缩型分别结合各自损伤机制、具体分度和涉及损伤部位建立了相对应的ICD-10编码。结论编码员在编码踝骨骨折工作中,不仅要熟悉Lauge-Hansen分型表示的具体内涵,还需结合病程记录、手术记录以及重要的影像学检查的阳性指征,对骨折明显的并发症和伴随症不漏编。Objective As a common disease in orthopedic clinic,ankle fracture is usually classified,diagnosed and treated by Lauge-Hansen standard,and coders should establish the corresponding relationship between them through ICD-10.Methods By understanding the anatomical structure of the ankle bone,five types of Lauge-Hansen classification,such as supination-external rotation,pronation-external rotation,supination-internal adduction,pronation-external abduction and vertical compression,were deeply understood,and were analyzed by ICD-10.Results The ICD-10 codes of supination-external rotation type,pronation-external rotation type,pronation-internal adduction type,supination-external abduction type and vertical compression type were established respectively according to their respective damage mechanism,specific index and involved sites.Conclusion Coders should not only be familiar with the specific connotation of Lauge-Hansen classification,but also need to combine the course records,operation records and important positive signs of imaging examination to ensure the obvious complications and concomitant symptoms of fracture were not omitted for coding.

关 键 词：踝骨骨折 Lauge-Hansen分型 ICD-10编码 案例分析 

分 类 号：R197.323.1[医药卫生—卫生事业管理]