阅读病理报告对肿瘤ICD编码的影响

The Influence of Correct Reading of Pathological Report to The ICD Coding of Tumors

病理报告作为重要的医疗文书,不仅在指导临床诊断与治疗疾病方面有着不可替代的重要作用,而且在ICD编码中同样具有不可或缺的作用和意义,实际工作中仅仅依靠病案首页中的病理诊断进行肿瘤形态学编码是不够的。笔者就肯定性、推测性、描述性及阴性病理报告,论述并举例说明不同类型病理报告ICD编码的特点及要点,提示一个合格的编码员必须学会阅读病理报告。

As an important medical material, the pathological report has not only played an irreplaceable role in the diagnosis and treatment of diseases, but also in the ICD coding. And in the real work, to make the morphology coding of tumors only according to pathological report is not enough. By the certainty, Speculation, descriptiveness and negative of the pathological report, the writer diseussed and illustrated the characters and key points of different types of pathological reports, and indicated that a eligible coder must manage the reading of pathological reports.