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目的根据食管损伤的病因及损伤部位,对食管损伤作出正确编码。方法对某院2010年1月1日-2014年4月30日出院诊断为食管损伤、食管破裂、食管穿孔的病案进行回顾性分析,依据《疾病和有关健康问题的国际统计分类》(ICD-10第二版)的分类要求,对食管损伤进行编码。结果 52份诊断为食管损伤、食管破裂、食管穿孔的病案中,食管异物引起的食管损伤、破裂、穿孔33份,占63.46%;自发性食管破裂、穿孔10份,占19.23%;创伤引起的食管破裂5份,占9.62%;医源性食管损伤、破裂、穿孔4份,占7.69%。结论食管损伤、破裂、穿孔作为临床诊断名称,不同的病因、不同的损伤部位有着不同的编码,编码员必须通过阅读病案资料,明确病因及部位,从而保证编码的正确性。
Objective According to the etiology of esophageal injury and the site of injury, correctly coded esophageal injury. Methods A retrospective analysis of the medical records of a hospital diagnosed as esophageal injury, esophageal rupture and esophageal perforation from January 1, 2010 to April 30, 2014 was conducted based on the International Statistical Classification of Diseases and Related Health Problems (ICD- 10 second edition) of the classification requirements of esophageal injury coding. Results Among the 52 cases diagnosed as esophageal injury, esophageal rupture and esophageal perforation, esophageal injuries, ruptures and perforations were caused by esophageal foreign bodies in 33 cases, accounting for 63.46%; spontaneous esophageal rupture and perforation in 10 cases, accounting for 19.23%; trauma-induced Esophageal rupture in 5, accounting for 9.62%; iatrogenic esophageal injury, rupture, perforated 4, accounting for 7.69%. Conclusions Esophageal injury, rupture and perforation are the names of clinical diagnosis, different etiologies and different lesions have different codes. The coder must read the medical records to clarify the etiology and location so as to ensure the correctness of coding.