| 浅析ICD-10疑难编码 |
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| 引用本文： | 冯素花,刘俊峰,黄相翠. 浅析ICD-10疑难编码[J]. 现代医院, 2010, 10(2): 137-138. DOI: 10.3969/j.issn.1671-332X.2010.02.068 |
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| 作者姓名： | 冯素花 刘俊峰 黄相翠 |
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| 作者单位： | 英德市人民医院,广东省英德,513000 |
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| 摘 要： | 目的探讨疑难编码的原因,提高ICD编码准确性。方法对8例ICD疑难编码的原因进行分析,应用ICD-10编码规则进行疾病分类。结果造成疑难编码的原因是:一方面临床医师书写诊断不规范,另一方面编码员医学知识欠缺。结论认真细致阅读病历、分析原因,了解疾病病因、病理、临床特征,并与临床医师勾通,掌握ICD-10操作分类基本原则,学习必要的临床医学知识和外语知识,方能准确编码。
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| 关 键 词： | ICD-10 疾病分类 疑难编码 |
A NARRATION OF ICD-10 DIFFICULT ENCODING |
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| FENG Suhua,LIU Junfeng,HUANG Xiangcui. A NARRATION OF ICD-10 DIFFICULT ENCODING[J]. Modern Hospital, 2010, 10(2): 137-138. DOI: 10.3969/j.issn.1671-332X.2010.02.068 |
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| Authors: | FENG Suhua LIU Junfeng HUANG Xiangcui |
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| Affiliation: | FENG Suhua,LIU Junfeng,HUANG Xiangcui Department of Information Technology,Yingde People's Hospital,Guangdong Province 513000 PRC |
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| Abstract: | Objective To investigate the reason of difficult encoding,improve the veracity of ICD encoding.Methods Eight cases of ICD difficult encoding was analyzed,applied ICD-10 coding rule to carry on a disease classification.Results The reason of difficult encoding as follows:On the one hand clinical doctor wrote diagnoses non-standard,on the other hand the encoder lack medical science knowledge.Conclusion To read medical record seriously and carefully,analyze reason,understand cause of disease,pathology,clinical ... |
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| Keywords: | ICD-10 |
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