三种先天性畸形疾病ICD-10编码实例分析

Cases Analysis on ICD-10 Coding of Three Congenital Malformation Diseases

在疾病分类工作中对于主导词的选择,需要根据不同情况而分别处理。分析总结Williams综合征、纤毛不动综合征3例疾病编码过程,有利于开拓编码思路,提高疾病分类的准确性。对于先天性畸形、变形和染色体异常疾病的疾病名称部分不是以病因或临床表现命名,不能直接从疾病名称中直接选择主导词。则需要查阅文献,了解这些疾病的其他命名,以多种渠道、多种思路选择主导词,并详细阅读病历,了解疾病的临床特征。在此基础上遵循编码步骤进行准确编码。

The choice of leading words in disease classification work needs to handle respectively depends on different situations. This paper ana- lyzes and summarizes 3 cases disease coding process of Williams syndrome and immotile cilia syndrome for opening up thinking and improving accuracy of disease classification. As for diseases name not naming for their etiology or clinical manifestation such as congenital malformation, deformation and chromosome abnormalities, we can not directly choose leading words from diseases name. Therefore, we need to look up literature for searching other names of these diseases, choosing leading words from different channel and different thinking, and to carefully read medical records for understanding clinical manifestation of diseases. At the basis, we can correctly have coding by following coding procedures.