心脏破裂疾病分类的探讨

目的 探讨心脏破裂(cardiac rupture简称CR)的ICD-10编码及分类原则.方法 选取某三甲医院2000年至2012年住院病人出院诊断包含有心脏破裂诊断病历26例,参考国际疾病分类规则,检查26份病历中心脏破裂(CR)的疾病编码情况.结果 26例心脏破裂病历中,CR疾病的总编码错误率高达73.08％.结论 编码员充分了解心脏破裂的相关医学知识,编码前仔细研读病历,准确区分心脏破裂的解剖部位、发病诱因、临床表现,熟练掌握心脏破裂(CR)的ICD编码原则,认真遵循编码操作步骤,才能做到准确编码.

Discussion on the ICD of Cardiac Rupture

Objective To discuss the ICD-10 coding and classified principle of cardiac rupture（CR）. Methods Selecting 26 medical records which discharge diagnosis including Cardiac rupture in a top three hospitals from 2000 to 2012. Referring to the rules of the international classification of diseases and checking codes of them. Results The total coding error rate of CR disease is as high as 73. 08%. Conclusion Coders should fully understand the relevant medical knowledge of cardiac rupture, poring over records before cod- ing, accurately distinguish the location, the predisposing factors and clinical manifestations of cardiac rupture, master ICD coding principles of cardiac rupture （CR）, carefully follow coding steps to achieve accurate coding.