7例宫颈环扎术ICD编码案例分析

Coding Analysis of Seven Related Cases of Cervical Cerclage

产科疾病涉及女性妊娠期、分娩期及产褥期的母体和胎儿的情况,在国际疾病分类中规则复杂,影响编码的因素多,错误率高。并且产科诊断的书写有其特点,有时相同的临床诊断,在不同情况下,疾病编码不同。本文以某产科7例行宫颈环扎术的病例为例,探讨习惯性流产、宫颈功能不全或异常的宫颈疾患在非妊娠期、妊娠期及分娩期诊疗目的和具体情形不同时如何正确分类编码,分析产科编码错误原因,并从临床医师和编码员的角度提出提高编码正确率的措施。只有医师了解疾病分类的规则和相关要点,规范书写病历内容和病案首页诊断信息的填写,编码员的专业理论水平提高,熟练掌握产科编码规则,养成良好的编码习惯,才能对相关病例进行准确完整的分类。

Obstetrical diseases involve the conditions of gravida and fetus during pregnancy, childbirth and puerperium. Correspondingly, in the International Classification of Diseases, there are complex rules and many factors affecting the coding,and the error rate is high. The writing of obstetric diagnosis has its own characteristics,which is likely correct according to the requirements of obstetrics,there are different codes in different situations even for the same diagnosis. Taking 7 cases of cervical cerclage in an obstetric department as the example, this article discusses how to correctly classify and code the habitual abortion, cervical insufficiency or abnormal cervix in non-pregnancy period, gestation period and delivery period respectively with different diagnosis, treatment purposes and specific situations, and analyzes the causes of obstetric coding errors. Only if clinicians understand disease-classification knowledge and standardize diagnosis and writing of the medical record information, and if coders improve their own knowledge with a good command of coding rules and good coding habits, record coding can be complete and accurate.