ICD-10编码在睡眠障碍中的应用

在研究睡眠障碍的相关病案时发现,实现准确编码对于病案首页数据内涵有重要的意义,同时也方便医疗经费的控制与管理.编码员在进行编码时,应仔细研究相关病案,分析病因,结合病案的实际情况,依照国际疾病分类原则,区分器质性与非器质睡眠障碍,同时根据鉴别结果给予相应的疾病分类编码.     

咽异常感的病因分类及治疗略论

咽异常感的病因分为器质性和非器质性。本文对其进行了分类,并将其分类用于临床诊断和治疗。在排除了器质性疾病引起的咽异常感之后,应用中药半夏厚朴汤治疗,获满意的治疗效果。分析了部分患者的心理状态,指出本病的治疗关键在于诊断的准确,对心理异常的患者要作解释工作。     

非器质性睡眠障碍患者认知功能研究进展

非器质性睡眠障碍是一类较为常见的精神疾病,易导致认知功能障碍,本文对国内外有关非器质性睡眠障碍患者认知功能的研究文献作一综述,为开展非器质性睡眠障碍患者认知功能研究提供参考.     

疾病分类编码不准确原因分析与对策

对疾病分类进行编码是医院病案室的重要工作内容之一，编码的正确与否直接影响医院病案统计资料的准确性，影响病案信息的检索和利用。有人对3000份产科病案的ICD-10编码的准确性进行调查，查出错误编码155份，占5．2。一般医院都重视病案质量，但对疾病分类编码的质量却少有人问津。现将疾病编码不准确原因与对策总结如下。     

就ICD-10编码中的问题与读者商榷

<疾病和健康有问题的国际统计分类>(简称ICD)编码是国际间信息交流的重要手段,编码工作随着医院管理的量化、细化、信息化,将直接影响到医院的医疗质量管理工作,影响到医院的信息化管理工作.然而,由于实际工作中的编码人员基本素质的参差不齐,编码工作中的错编和漏编现象时有发生,从而严重影响到病案检索、查询工作的准确进行[2],也直接影响统计分类的准确与否,现就我院ICD-10启用以后所出现的问题,与同行商榷.     

869例流产病例ICD-10编码逻辑核查分析

目的探讨流产ICD-10编码的错误情况,找出对策。方法对869例流产病例在病案统计管理系统的综合查询菜单中设置逻辑条件进行核查,根据流产的临床诊断标准和ICD-10分类原则进行分析讨论。结果流产应该根据其目的、孕周、并发症和伴随疾病等具体情况进行分类。结论逻辑核查可以批量对ICD编码进行质控,可以高效、精确地发现问题所在,提高编码准确率。     

从灾难新闻中培养ICD编码能力

目的：以灾难新闻中有关疾病分类编码的题材，来促进病案管理人员ICD-10编码素质的提高。方法：分析“人感染猪链球菌”、“龙华街道特大车祸”、“卡特里娜飓风”灾难事件和医疗救助新闻，探讨对应的ICD-10编码。结果：可以提升病案管理人员编码的主动服务意识，培育正确的编码素养，形成开放互动的编码探讨氛围。结论：从灾难新闻中培养ICD编码能力的做法，值得推广。     

2例心因性疾病患者的心理护理

心因性疾病在《国际疾病分类》第10版（ICD10）和精神障碍诊断和统计手册第4版（DSM—IV）中被分别称为分离障碍和转换障碍，主要是指由心理因素引起的、没有器质性疾病基础的躯体和精神症状。医师或患者及其家属误认为患有严重疾患，通常患者会不停地往返各家医院作检查，面对检查报告显示的正常结果又常常束手无策，本文对2例确诊为心因性疾病的患者运用心理学技术治疗，获得了满意的疗效。现报道如下。     

康复治疗影响国际疾病分类因素的分析

目的:加强临床医师和疾病分类人员对康复治疗疾病分类的认识,提高康复治疗疾病分类编码的准确性及病案资料检索利用的质量。方法:利用Foxpro建立病案资料数据库,以国际疾病分类(ICD-9)的编码原则为标准,回顾性检索1998-01/2002-12新桥医院住院进行康复治疗的病例,所有病例以出院的第1诊断为检索对象。结果:检索出康复治疗疾病分类的误码667例,主要发生在循环系统、精神疾患系统、损伤和中毒系统、神经系统、肌肉骨骼系统、影响健康状态系统(V编码)和传染病系统的疾病分类编码。结论:康复治疗疾病分类编码的准确率,直接影响临床、科研及教学对病案信息资料检索利用的质量。     

1987～2000年间轻度脑外伤在瑞典医院的情况

目的　为了评价轻度脑外伤(mildtraumaticbraininju ry,MTBI)在瑞典的发生率和发生因素,进行了回顾性人群 发生率队列研究。 资料与方法　所有患者选自1987～2000年间,通过国 际疾病分类法ICD 9(分类编码850,1987～1996年)和ICD 10(分类编码S06.0,1997～2000年)诊断为MTBI的瑞典 住院患者。数据资料来源于瑞典国家卫生和福利委员会的 医院公布记录(…     

组配法在医药卫生科学数据分类编码中的应用

目的探讨组配方法在医药卫生科学数据分类与编码中的应用,建立医药卫生科学数据的多轴分类集合,实现科学数据的规范表达和有效管理.方法采用组配方法,对医药卫生科学数据设计分段编码方案.结果主分类表设计5个码位,表示三个层级,即门类（第一位）字母码、亚门类（第二、三位）数字码和大类（第四、五类）数字码;复分类表等同采用既定分类方法中的分类编码体系.结论组配法与传统分类法相结合可实现分类法等级列举式向分面组配式发展,从而达到对医药卫生科学数据归并和信息组织的目的.     

The EASTR study: a new approach to determine the reasons for transfusion in epidemiological studies

summary Previous studies of blood use have used different methods to obtain and classify transfusion indications. Before undertaking a national study of transfusion recipients, a pilot study was performed over 2 months at two teaching and two district general hospitals to match information from hospital transfusion laboratories with clinical coding data from the hospital’s Patients Administration System to determine the indication for transfusion in 2468 recipients. Data analysis revealed major limitations in the conventional use of primary diagnostic International Statistical Classification of Disease and Related Health Problems 10th Revision (ICD‐10) or procedure Office of Population, Censuses and Surveys – Classification of Surgical Operations and Procedures – 4th Revision (OPCS‐4) codes alone in allocating transfusion indications. A novel algorithm was developed, using both types of code, to select the probable indication for transfusion for each patient. A primary OPCS‐4 code was selected for recipients transfused in relation to surgery (43%) and either the primary (36%) or the secondary (12%) ICD‐10 code was chosen for recipients transfused for medical reasons. The remaining patients were unclassified. Selected codes were then collated into Epidemiology and Survival of Transfusion Recipients (EASTR) casemix groups (E‐CMGs). The most frequent E‐CMGs were haematology (15% of recipients), musculoskeletal (14%), digestive system (12%) and cardiac (10%). The haematology E‐CMG includes patients with malignant and non‐malignant blood disorders and recipients transfused for anaemia where no cause was listed. Recipients undergoing hip and knee replacement and coronary artery bypass grafting are within the musculoskeletal and cardiac E‐CMGs. The digestive E‐CMG includes recipients transfused for gastrointestinal (GI) bleeds and those undergoing GI surgery. This methodology provides a more useful means of establishing the probable indication for transfusion and arranging recipients into clinically relevant groups.     

Drug dependence is not addiction—and it matters

Accurately identifying persons with addiction is critically important for effectively targeting treatment and harm reduction interventions. Misdiagnosis of addictive disorders can lead to a cascade of negative outcomes, including stigma, discontinuation of needed medications, undue scrutiny of both patients and physicians, and even criminal consequences. A recent study raises significant concerns about the accuracy of diagnosis code data, likely rooted in confusingly-worded International Classification of Diseases (ICD)-9 and ICD-10 codes and a general misunderstanding of the difference between addiction and physiologic dependence. It is hardly surprising that physicians frequently mislabel patients when the ICD terms used to code for addiction are themselves misleading. ICD codes have not been updated to reflect current understanding of addiction, unlike those in the DSM-5. To explore this issue further, this commentary briefly discusses new information regarding coding data inaccuracies, how coding inaccuracies can lead to misdiagnosis, and the dangers of conflating “addiction” with “dependence.” The commentary concludes with a call for the ICD to update their codes to reflect current understanding of addiction.

Key messages

• It is not surprising that physicians frequently conflate patients with “addiction” and “dependence” when the ICD terms used to code for addiction are themselves misleading.
• ICD codes have not been updated to reflect what we know about the nature of addiction, unlike those in the DSM-5.
• This commentary calls for the ICD to update their codes to reflect current understanding of addiction.

     

Sleep disorders

Humans spend approximately one third of their lives asleep. Although the same medical disorders that occur during wakefulness persist into sleep, there are many disorders that occur exclusively during sleep or are manifestations of a disturbance of normal sleep-wake physiology. The most common reason for referral to a sleep laboratory is OSA, whereas the most common sleep disorder is insomnia. Effective treatments now exist for many sleep disorders, such as OSA and RLS, and a major breakthrough in the treatment of narcolepsy seems imminent. Because all disease processes are adversely affected by insufficient sleep, it is essential that the practicing physician understand the causes and treatments of the common sleep disorders.     

医药卫生科学数据分类与编码的研究

目的研究医药卫生科学数据的分类与编码方法,以保证科学数据得到有效的管理.方法采用线分类法,建立医药卫生科学数据分类框架;使用组配技术进行编码,实现体系分类法的组配化,建立医药卫生科学数据的多轴分类集合.结果建立了医药卫生科学数据分类框架;确立了医药卫生科学数据分类框架类目内容;设计了医药卫生科学数据编码方案.结论分类编码研究实现了针对数据的归并和信息的组织.     

新型冠状病毒肺炎疫情下医护人员睡眠障碍影响因素的质性研究

目的深入了解新冠病毒肺炎疫情下医护人员出现睡眠障碍的原因,为改善其睡眠质量提供参考。方法采用目的抽样选取2020年1月26日—3月14日福建省第一批进入金银潭医院进行救治任务而出现睡眠障碍的10名医护人员为研究对象,以质性研究中Colaizzi现象学方法为指导,采用微信视频面对面访谈的方式了解医护人员出现睡眠障碍的原因。结果多种因素可影响医护人员的睡眠障碍,归纳为睡眠习惯的改变、对疫情的过分担心、环境和生活方式的改变、职业压力的影响、院感防护的影响。结论在新型冠状病毒肺炎疫情影响下一线医护人员睡眠质量不佳,应帮助医护人员从生理、心理各方面进行调节,提高其睡眠质量。     

Using clinical data for nursing research and management in health services

Nurses generate large quantities of data at different operational levels in a health service organization. Administrative managerial data include the number of nursing hours per patient day and cost data related to nursing services while clinical data include the documentation of direct patient care only. In this paper, we explain standard clinical data elements in the HIS (Hospital Information System). The construction of the data is traced from patients' medical records to coding procedures within ICD (International Classification of Disease) classification and DRG (Diagnostic Related Groups) of casemix. Examples are given from Australian data and definitions, but much of the same information can be found in hospital information systems throughout the world. Practical applications that demonstrate how patient data can be used for research and management purposes in nursing are given. Finally, future directions and issues related to the use of datasets for nursing research are explored.     

老年糖尿病患者睡眠障碍原因及护理对策

随着经济社会发展,中国逐渐步入老龄化社会,老龄化的迅速发展要求医务人员采取积极的护理措施以控制睡眠障碍对老年人的影响,对提高老年人的生命质量极其重要.据调查显示,60岁以上的老年人57%会出现睡眠障碍.本文主要研究分析老年人睡眠障碍的原因及临床表现,重视睡眠障碍的危害和不良影响,通过研究有效的护理措施,希望能够指导临床与护理工作者做好老年人睡眠障碍的护理工作,帮助老年人积极应对睡眠障碍,保证其能够健康快乐地享受晚年生活.