摘要
Chiari畸形是一种先天性颅颈交界区畸形,以小脑扁桃体通过枕骨大孔不同程度的下疝为主要特征。如果简单按照临床诊断名称的习惯叫法,编码员很容易将Chiari畸形疾病分类到Q04脑的其他先天性畸形,造成编码错误。准确解读Chiari畸形的临床分型与临床表现,分析Chiari畸形疾病编码的查找过程,总结查找疑难疾病编码时,要阅读分析病案及查阅相关文献资料,充分理解疾病的性质和内涵,有效转换主导词进行编码。ICD-10编码是一门具有一定技术难度和复杂性的专门学科,编码员必须熟练掌握ICD-10的分类规则,具有强烈的责任心,与临床医师充分沟通和交流,具备一定的相关医学知识和外语知识,才能提高疑难疾病编码的准确性。
Chiari malformation is a congenital craniocerebral junction deformity, with cerebellar tonsils as the main feature of different degrees of chin under the occipital foramen. If you simply follow the customary name of the clinical diagnosis, the coder can easily classify the Chiari malformation disease into other congenital malformations of the Q04 brain, causing coding errors. By accurately interpreting the clinical classification and clinical manifestations of Chiari malformation, this paper analyzes the search process of Chiari malformation disease coding,summarizes the search for difficult disease codes, reads the analysis of medical records and consults relevant literature, fully understands the nature and connotation of the disease, and effectively converts The dominant word is encoded. ICD-10 coding is a specialized discipline with certain technical difficulty and complexity. The coder must be proficient in the classification rules of ICD-10, have a strong sense of responsibility, fully communicate and communicate with clinicians, and have certain relevant medical knowledge. And foreign language knowledge can improve the accuracy of difficult disease coding.
作者
李江南
陈安琪
Li Jiangnan;Chen Anqi(The Affitiated Huai’an Hospital of Xuzhou Medical University, Huai’an 223002,Jiangsu Pnovince, China)
出处
《中国病案》
2019年第1期21-24,共4页
Chinese Medical Record
基金
江苏省卫生计生委课题(J201609)
