| 先天性畸形、变形和染色体异常疾病编码疑难解析 |
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| 引用本文： | 杨丰,梁耀.先天性畸形、变形和染色体异常疾病编码疑难解析[J].现代医院,2010,10(2):135-136. |
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| 作者姓名： | 杨丰 梁耀 |
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| 作者单位： | 广东医学院附属医院,广东广州,524001 |
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| 摘 要： | 目的为提高先天性畸形、变形和染色体异常的疾病编码正确率及疾病的分类水平。方法以黑斑息肉病、茎突综合征、心肌桥为例,进行编码及分类过程的阐述。结果在先天性畸形、变形和染色体异常疾病的编码分类过程中,当疾病的名称和编码表中的病名不一致或不完全一致时,必须查阅病历,了解临床诊断的依据,同时,与临床知识及经验丰富的临床医生沟通,才能正确编码分类,否则,很难编码或编码错误,从而影响病案资料的查询和统计信息的真实性。结论要正确编码分类先天性畸形、变形和染色体异常的疾病,编码员必须有高度责任心,熟悉ICD的技术及疾病编码原则,编码前必须查阅相关病历资料,与主管临床医师充分交流。
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| 关 键 词： | 先天性疾病 国际疾病分类 编码 |
RESOLUTION OF THE DISEASE CODING DIFFICULTY FOR CONGENITAL MALFORMATION,TRANSFIGURATION AND CHROMOSOME ABNORMITY |
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| YANG Feng,LIANG Yao.RESOLUTION OF THE DISEASE CODING DIFFICULTY FOR CONGENITAL MALFORMATION,TRANSFIGURATION AND CHROMOSOME ABNORMITY[J].Modern Hospital,2010,10(2):135-136. |
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| Authors: | YANG Feng LIANG Yao |
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| Institution: | YANG Feng,LIANG Yao The Affiliated Hospital of Guangdong Medical College,Zhanjiang,Guangdong Province 524001 PRC |
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| Abstract: | Objective To advance right rate of disease coding and level of disease assorting of congenital malformation,transfiguration and chromosome abnormity.Methods To expatiated coding and assorting course of Peutz-Jeghers Syndrome,Eaglesyndrome and Myocardialbridge.Results When the disease name is not or incompletly accord with the disease name of coding list in the coding and assorting course of congenital malformation,transfiguration and chromosome abnormity,the coder must consult case history,and realize gist ... |
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| Keywords: | Congenital Disease International Classification of Diseases(ICD) Code |
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