儿童恶性肿瘤病案首页主要诊断选择及ICD-10编码分类的案例分析  

Primary Diagnosis Selection and Case Analysis of ICD-10 Coding Classification in Home Page of Medical Records of Pediatric Malignant Tumors

作　　者：韩璐 HAN Lu(Shenzhen Children's Hospital,Shenzhen,Guangdong,518000,China)

机构地区：[1]深圳市儿童医院,广东深圳518000

出　　处：《中国卫生质量管理》2024年第8期38-40,45,共4页Chinese Health Quality Management

摘　　要：目的为恶性肿瘤患儿病案首页主要诊断选择提供参考。方法结合主要诊断的选择总则以及恶性肿瘤主要诊断的选择原则,对恶性肿瘤患儿的主要住院目的和治疗方式进行分类,探讨不同住院目的及不同治疗方式下的病案首页主要诊断选择及ICD-10编码分类。结果患儿首次就医,主要对原发恶性肿瘤或继发恶性肿瘤进行治疗,分别选择原发或继发恶性肿瘤作为主要诊断。患儿非首次就医:主要来院化疗,选择不同治疗阶段对应的化疗诊断作为主要诊断;主要来院行造血干细胞移植,选择原发恶性肿瘤作为主要诊断;主要来院行骨穿或腰穿评估,选择相应化疗后或免疫治疗后的随诊检查作为主要诊断;主要来院输血小板、红细胞或升白细胞,选择化疗后骨髓抑制作为主要诊断;主要来院输注单抗,选择恶性肿瘤免疫治疗作为主要诊断;主要来院输注NK细胞或间充质干细胞,选择细胞治疗作为主要诊断;主要对并发症治疗,选择相应治疗的并发症作为主要诊断;患儿治疗期间死亡,选择原发恶性肿瘤作为主要诊断。结论在选择主要诊断时,应兼顾住院目的和与主要治疗方式的一致性,以实现更精准的DRG分组。Objective To provide a reference for the selection of the principal diagnosis in the home page of medical records of pediatric malignant tumors.Methods Combined with the general principles of the selection of major diagnosis and the selection principles of major diagnosis of malignant tumors,the main hospitalization purposes and treatment methods of children with malignant tumors were classified,and the selection of major diagnosis and ICD-10 coding of the home page of medical records under different hospitalization purposes and different treatment methods were discussed.Results For the first admission,the primary malignant tumor or secondary malignant tumor was mainly treated,and the primary or secondary malignant tumor was selected as the primary diagnosis.Children with non-first admission and mainly for chemotherapy,the chemotherapy diagnosis was selected corresponding to different treatment stages as the primary diagnosis.For the admission purpose of hematopoietic stem cell transplantation,and primary malignant tumor was selected as the primary diagnosis.For admission for bone puncture or lumbar puncture evaluation,the follow-up examination after corresponding chemotherapy or immunotherapy was selected as the primary diagnosis.For children with platelet,red blood cell or leukocyte transfusion,myelosuppression after chemotherapy was chosen as the primary diagnosis.The admission for infusion of monoclonal antibody,malignant tumor immunotherapy was selected as the primary diagnosis.The admission for NK cells or mesenchymal stem cells injection,the cell therapy was selected as the primary diagnosis.The admission for the treatment of complications,the corresponding treatment of complications were selected as the primary diagnosis.If the patient died during treatment,the primary malignancy was chosen as the primary diagnosis.Conclusion When selecting the primary diagnosis,it is important to consider both the purpose of hospitalization and consistency with the primary treatment approach in order to achieve more accu

关 键 词：儿童 恶性肿瘤 病案首页 主要诊断 ICD-10编码 

分 类 号：R197.5[医药卫生—卫生事业管理] R73[医药卫生—公共卫生与预防医学]