产科巨大儿ICD-10编码案例分析

Case study on the ICD-10 Coding of Obstetrics"Fetal Macrosomia"

根据巨大儿的定义及在ICD-10中编码选择原则,通过结合临床实际病例展开论述,分析巨大儿相关疾病编码错误的原因及解决方案。产科巨大儿编码可分为三种情况:第一种是产前已诊断或未诊断为巨大儿的,通过自然分娩证实的应编码到O36.6;第二种是产前已诊断为巨大胎儿并作为手术指征进行剖宫产分娩的应编码到O33.5;第三种是由于特大胎儿造成梗阻性分娩的应编码到O66.2。针对各种原因造成的巨大儿分类错误,提出了应对措施,如:通读病案资料;与临床医师进行充分有效的沟通;严格按照编码查找方法进行编码查找、核对;加强本专业及临床知识的学习等具体措施,保证编码员充分理解病案内容,才能正确进行产科巨大儿的编码分类工作,为医疗数据的准确性奠定基础。

According to the definition of giant infants and the principle of coding selection in ICD-10,combined with actual clinical cases,the reasons and solutions of coding errors related to giant infants are analyzed.The coding of obstetric macrosomia can be divided into three situations:the first type is diagnosed or undiagnosed as a macrosomia before delivery,and the coded as O36.6 is confirmed by natural delivery;the second type is a macrosomia that has been diagnosed before delivery And as an indication for surgery,cesarean section delivery should be coded to O33.5;the third is the obstructive delivery due to an extra-large fetus should be coded to O66.2.In response to the huge misclassification of infants caused by various reasons,countermeasures have been proposed,such as:reading through medical records;communicating fully and effectively with clinicians;performing code search and verification in strict accordance with code search methods;strengthen the study of this specialty and clinical knowledge Specific measures such as ensuring that the coders fully understand the content of the medical records can correctly perform the coding and classification of obstetric giant infants,laying the foundation for the accuracy of medical data.