论文部分内容阅读
目的了解ICD-10中对某些肿瘤性疾病适用于双重分类即星剑号编码。但临床医师在住院病案首页上往往不将肿瘤和它引起的疾病联合填写,对编码造成一定难度。方法编码人员分类编码时,要参阅病案实际内容进行编码。结果确定与肿瘤相关联的疾病,根据ICD-10规则给予双重分类,并按照卫生部规定以剑号编码作统计上报。结论编码员一定牢记不能只看病案首页上书写的诊断进行编码,否则容易产生编码的错误。
Objective To understand that ICD-10 is suitable for dual classification of some neoplastic diseases such as Star Sword coding. However, clinicians often do not fill in the tumor and the diseases caused by it on the first page of the inpatient medical record, which causes some difficulty in encoding. Method Coding staff classified coding, the actual content of the case to be coded. Results The disease associated with the tumor was identified and double-classified according to the ICD-10 rule and reported as a Sword number according to Ministry of Health regulations. Conclusion The coder must remember that you can not just look at the diagnosis written on the first page of the medical record, otherwise it is prone to coding errors.