恶性肿瘤预防性治疗的主要诊断选择和ICD编码  

Primary Diagnosis and ICD Coding of Preventive Therapy

作　　者：张弘 赵丹丹 尹世全 王凯鹏 Zhang Hong;Zhao Dandan;Yin Shiquan;Wang Kaipeng(Department of Medical Record,National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing 100021,China)

机构地区：[1]国家癌症中心,国家肿瘤临床医学研究中心,中国医学科学院北京协和医学院肿瘤医院病案科,北京市100021

出　　处：《中国病案》2023年第6期59-61,共3页Chinese Medical Record

摘　　要：分析预防性治疗恶性肿瘤5个病例,总结不同类型预防性治疗的主要诊断选择及其ICD-10编码。乳腺癌女性患者行去势术、遗传性卵巢癌高危患者行卵巢预防性切除术,其主要诊断均选择Z40.0与恶性肿瘤有关的危险因素的预防性手术;对癌前病变进行预防性扩大切除手术,主要诊断选择相应的疾病;针对未发生疾病的器官进行预防性放疗,主要诊断选择Z51.0放射治疗;针对癌前病变行预防性化疗,主要诊断选择Z51.2化学治疗。实际工作中需仔细阅读病案,积极与临床医师沟通,查阅文献,注意区别预防性手术和补充扩大手术,预防性治疗与手术后辅助治疗。To analyze five cases for the preventive therapy of malignant tumors,and to summarize the primary diagnosis and ICD-10 codes.For female patients with breast cancer underwent castration,and high-risk patients with hereditary ovarian cancer underwent prophylactic ovariectomy,the primary diagnosis was Z40.0 prophylactic surgery for risk-factors related to malignant neoplasms;preventive extended resection was performed for precancerous lesions,and the primary diagnosis was the corresponding diseases;preventive radiotherapy was carried out for organs without disease,and the primary diagnosis was Z51.0 radiotherapy session;Z51.2 other chemotherapy was the primary diagnosis for prophylactic chemotherapy for precancerous lesions.It is necessary to carefully read the medical records,communicate with clinicians,review literature.The difference between preventive surgery and supplementary expanded surgery,preventive treatment and postoperative adjuvant treatment should be carefully identified.

关 键 词：预防性治疗 主要诊断 国际疾病分类 

分 类 号：R197.323[医药卫生—卫生事业管理]