伴有心力衰竭病例的主要诊断选择探讨  

Discussion on Main Diagnosis Selection of Medical Records with Heart Failure Diagnosis

作　　者：王卫卫[1] 赵慧智[1] 王晶晶[1] 李珊[1] Wang Weiwei;Zhao Huizhi;Wang Jingjing;Li Shan(Hebei People's Hospital,Shijiazhuang 050051,Hebei Provinre,China;不详)

机构地区：[1]河北省人民医院,河北省石家庄市050051

出　　处：《中国病案》2021年第5期44-46,共3页Chinese Medical Record

基　　金：河北省2019年度医学科学研究重点课题计划(20190212)

摘　　要：选取某院2018年度伴有心力衰竭诊断的5个典型病案,探讨主要诊断的选择。伴有心力衰竭诊断的患者就医情况复杂,常多种疾病并存,心力衰竭分级较高或分期较晚时,提示疾病发展达到严重阶段。伴有心力衰竭病例选择主要诊断时,质控编码员应详细阅读病案,加强与临床医师沟通,结合患者来院目的,综合考虑病因与临床表现之间的关系、心力衰竭的分级与分期、疾病的发展阶段、住院过程的诊治重点等因素,灵活应用主要诊断选择原则;未针对病因进行治疗时,病因不能作为主要诊断;合并编码对应疾病名称可以解释多种临床表现或可以同时解释病因和临床表现时,应考虑合并编码的正确应用。Five typical medical records with heart failure diagnosis in the hospital in 2018 were selected to explore the main diagnosis options of medical records with heart failure diagnosis.Patients with heart failure diagnosis have complicated medical conditions,often coexist with multiple diseases.When heart failure is graded higher or the stage is late,it indicates that the disease has reached a serious stage.When choosing the main diagnosis for the medical record with heart failure diagnosis,the quality control coder should read the medical record in detail,strengthen the communication with clinicians,combine with the purpose of patients coming to the hospital,comprehensively consider the relationship between etiology and clinical manifestations,the classification and staging of heart failure,the development stage of disease,the diagnosis and treatment focus of hospitalization process,etc.,and flexibly apply the main diagnosis selection principle.When the etiology is not treated,the etiology cannot be used as the main diagnosis;when the disease name corresponding to the combination code can explain multiple clinical manifestations or can explain the etiology and clinical manifestations at the same time,the correct application of the combination code should be considered.

关 键 词：主要诊断 心力衰竭 疾病诊断相关分组 病案首页 合并编码 

分 类 号：R541.6[医药卫生—心血管疾病]