主要诊断编码实例分析

Cases Analysis of Main Diagnostic Coding

国际疾病分类编码工作中经常会遇到一些疑难问题,通过对CREST综合征、Caroli病、Terson综合征、系统性血管炎四例疾病编码的分析,探讨几种查找疑难编码的方法。在实际工作中应学会运用多种手段来查阅,尤其是运用网络来查找。对于像CREST综合征这一类由疾病临床表现中英文首字母联合命名的疾病,要选用主要临床表现作为主导词查找;像Caroli病、Terson综合征这类由人名命名的疾病,必须通过各种手段查找其病因、病理、临床表现来确定主导词,准确运用编码原则,有的需要星剑号双重编码才能准确编码;对于系统性血管炎这类比较笼统的诊断,必须仔细阅读病历,尤其是病理、实验室特点,才能提高编码的准确性。

We always meet some difficult and complicated codes during ICD coding. Through analysis on diseases coding of CREST syndrome, Caroli＇disease, Syndrome of Terson and systemic vasculitis, this paper discusses several methods of finding difficult coding. At actual work, we must find the dominant word in different way, especially by internet. As for Syndrome of CREST named by the initials of clinical symptom, we may choose the main clinical symptom as the dominant word. As for Caroli＇ disease and Syndrome of Terson named after somebody, we must figure out the cause, pathology and clinical manifestation to determine the dominant word using the disease coding principles, particularly the Star dagger double coding prin- ciples. As for the general diagnosis like systemic vasculitis, we must carefully read the medical records, especially the pathology and the laboratory tests which may improve the accuracy of coding.