艾滋病主要诊断选择和ICD-10编码的探讨  

Discussion on the Main Diagnostic Options and ICD-10 Coding of AIDS Patients

作　　者：高丹红 郑方 沈银忠[1] 陆翠珍 颜闽 陆金风 孙丹凤[1] Gao Danhong;Zheng Fang;Shen Yinzhong;Lu Cuizhen;Yan Min;Lu Jinfeng;Sun Danfeng(Shanghai Public Health Clinical Center,Shanghai 20150&China;不详)

机构地区：[1]上海市公共卫生临床中心,上海市201508

出　　处：《中国病案》2022年第4期22-24,共3页Chinese Medical Record

摘　　要：艾滋病病程分为急性期、无症状期和艾滋病期,不同的分期对应不同的ICD编码。HIV/AIDS患者的免疫系统受到不同程度的损害,因此并发症往往不是单一的,在使用B20-B24编码时,一般不要将HIV病所引起的并发症与HIV病分别编码,且同时要注意“.7”规则。本文通过回顾某院艾滋病患者主要诊断和编码错误较为集中的几个问题,包括错误选择主要诊断,未使用合并编码、HIV特殊编码规则、错误编码艾滋病各临床分期的几个案例进行剖析,总结导致错误编码发生的原因为编码员缺乏对艾滋病临床专业知识的了解,欠缺对该专业编码规则的掌握,以及临床医师疾病诊断名称的不规范书写。通过提升编码人员临床专业知识,提高编码人员编码水平,加强临床医师规范书写诊断名称的措施,进而提高主要诊断的正确选择以及ICD-10编码填写的精准性。The course of AIDS is divided into acute stage,asymptomatic stage and AIDS stage,and different stages correspond to different ICD codes.The immune system of patients with HIV/AIDS is damaged to varying degrees,so the complications are often not single.When using B20-B24 coding,we should not code the complications caused by HIV disease and HIV disease separately,and we should pay attention to the ″.7″rule at the same time.In this paper,we reviewed several problems of the main diagnosis and coding errors of AIDS patients in a hospital,including wrong selection of the main diagnosis,not using combined coding,HIV special coding rules,and wrong coding of AIDS clinical stages.We summarized that the reason for the error coding was that the coders lacked the understanding of AIDS clinical professional knowledge,Lack of professional coding rules,as well as clinicians disease diagnosis name of non-standard writing.By improving the clinical professional knowledge of the coding staff,improving the coding level of the coding staff,and strengthening the measures for clinicians to standardize the writing of diagnosis names,we can improve the correct selection of main diagnosis and the accuracy of ICD-10 coding.

关 键 词：艾滋病 主要诊断 ICD-10编码 

分 类 号：R512.91[医药卫生—内科学] R197.323[医药卫生—临床医学]