上消化道出血的疾病分类编码分析

目的分析探讨上消化道出血不同部位的疾病诊断编码。方法利用“疾病和有关健康问题的国际统计分类ICD-10”对某三甲医院2011年7月1日至2012年6月30日主要诊断为上消化道出血的101份病案，从主导词的选择到疾病诊断编码进行分析。结果医生诊断为上消化道出血，编码于K92．2的101份病案中，行胃镜检查的共92份，占全部病例的91．09％。重新阅读已行胃镜检查的92份病案，其中胃溃疡出血及胃粘膜病变出血共23例，占25％；十二指肠溃疡出血2例，占2．17％；食管静脉曲张破裂出血及食管贲门粘膜裂伤共67例，占72．83％。结论编码员在日常工作中不但要掌握编码知识，还应仔细阅读病案，学习相关医学知识，做到编码准确，更好的服务于医疗、教学及科研。

Analysis of Diseases Classification of Upper Gastrointestinal Bleeding

To analyze and explore disease coding analysis of different parts of upper gastrointestinal bleeding. Methods We used ＂dis- eases and related health problems of international statistical classification of ICD-10＂ to analyze 101 copies of medical records from July 1,2011 to June 31, 2012 diagnosed of upper gastrointestinal bleeding of the tertiary general hospital from the choice of the leading words to diagnosis coding, Results Coding of K92.2 of 101 copies of medical records, 92 underwent endoscopy, which accounted for 91.09 % of all cases diagnosed of upper gastrointesti- nal bleeding by doctors. We read the 92 copies of medical records underwent endoscopy again and found 23 cases of gastric ulcer bleeding and gastric mucosal lesions bleeding, accounting for 25% ; 2 cases of duodenal ulcer bleeding, accounting for 2.17% ; 67 cases of esophageal variceal bleeding and esophageal mucosal laceration, accounting for 72.83 %. Conclusion Coders should not only master the coding knowledge, but also read medical records carefully, learn related medical knowledge and code accurately in their daily work to serve medical treatment, teach and research better.