腹腔脓肿的ICD-10编码

Coding Analysis of Abdominal Abscess in ICD-10

目的根据腹腔脓肿的病因及发生部位,对腹腔脓肿作出正确的ICD-10编码。方法对某院2009年4月1日-2013年3月31日出院诊断为腹腔脓肿的病案进行回顾性分析,根据其病因及发生部位,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,对腹腔脓肿进行编码。结果 57份诊断为腹腔脓肿的病案中,原发性腹腔脓肿7份,占12.28%;继发性腹腔脓肿50份,占87.72%。结论腹腔脓肿作为临床医师常用的诊断名称,编码员必须通过阅读病案资料,明确引起腹腔脓肿的病因及脓肿部位,从而保证腹腔脓肿编码的正确性。

Objective To make right ICD-10 coding on abdominal abscess according to its etiology and position. Methods To make a retrospectively analysis on the medical records with discharge diagnosis was abdominal abscess in our hospital from April 1st 2009 to March 31th 2013. Then to make codings of abdominal abscess according to the requirements in ＂Diseases and Related Health Problems of the International Statistical Classification＂ （ICD-10 second version）, as well as the etiology and position. Results In the 57 cases of medical records for the diagnosis of abdominal abscess, 7 cases were primary abdominal abscess, accounting for 12.28%, 50 cases were secondary abdominal abscess, accounted for 87.72 %. Conclusions As clinicians commonly used diagnostic name, coders must clear the etiology and position of abdominal abscess through reading the medical record information, therefore guarantee the ac- curacy of abdominal abscess coding.