浅析下消化道出血的疾病分类编码

Classification and Coding for Lower Gastrointestinal Bleeding Diseases

目的探讨下消化道出血的病因及其疾病分类编码。方法利用"疾病和有关健康问题的国际统计分类ICD-10"对某区二甲综合医院2012年6月1日至2014年5月31日主要诊断为下消化道出血的200份病案,从主导词的选择到疾病诊断编码进行分析。结果医生诊断为下消化道出血,编码K92.2的200份病案中,肠癌和肠炎引起的下消化道出血占了大比例,其次是息肉、肛门疾病及其他原因。结论疾病编码要按分类原则,当查到病因时要按病因编码。编码员在日常工作中不但要掌握编码知识,还应仔细阅读病案,学习相关医学知识,做到编码准确,更好的服务于医疗、教学及科研。

Objective To discuss the cause of lower gastrointestinal bleeding and its classification and coding. Method Use ＆quot;ICD-10 International Statistical Classification of Diseases and Related Health Problems＆quot; to analyze 200 medical records with primary diagnosis of lower gastrointestinal bleeding from June 1, 2012 to May 31, 2014 in a grade-A hospital of second class in a district from dominant word choice to disease diagnosis coding. The result shows that, among the 200 medical records that were diagnosed by doctor to be lower gastrointestinal bleeding and encoded in K92.2, lower gastrointestinal bleeding caused by intestinal cancer and anal diseases accounts for a large proportion, followed by polyps, enteritis and other causes. Conclusion Code the disease according to the principle of classification, and code the disease according to the cause if it is found. Coders in their daily work should not only master the coding knowledge, but also read carefully the medical records and study the relevant medical knowledge, to ensure accurate coding and better serve for medical treatment, teaching and research.