CAJ | 학술논문

目的分析探讨上消化道出血不同部位的疾病诊断编码.方法利用“疾病和有关健康问题的国际统计分类ICD-10”对某三甲医院2011年7月1日至2012年6月30日主要诊断为上消化道出血的101份病案,从主导词的选择到疾病诊断编码进行分析.结果医生诊断为上消化道出血,编码于K92.2的101份病案中,行胃镜检查的共92份,占全部病例的91.09%.重新阅读已行胃镜检查的92份病案,其中胃溃疡出血及胃粘膜病变出血共23例,占25%;十二指肠溃疡出血2例,占2.17%;食管静脉曲张破裂出血及食管贲门粘膜裂伤共67例,占72.83%. 结论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.
목적분석탐토상소화도출혈불동부위적질병진단편마.방법이용“질병화유관건강문제적국제통계분류ICD-10”대모삼갑의원2011년7월1일지2012년6월30일주요진단위상소화도출혈적101빈병안,종주도사적선택도질병진단편마진행분석.결과의생진단위상소화도출혈,편마우K92.2적101빈병안중,행위경검사적공92빈,점전부병례적91.09%.중신열독이행위경검사적92빈병안,기중위궤양출혈급위점막병변출혈공23례,점25%;십이지장궤양출혈2례,점2.17%;식관정맥곡장파렬출혈급식관분문점막렬상공67례,점72.83%. 결론편마원재일상공작중불단요장악편마지식,환응자세열독병안,학습상관의학지식,주도편마준학,경호적복무우의료、교학급과연.
Objective To analyze and explore disease coding analysis of different parts of upper gastrointestinal bleeding .Methods We used “dis-eases and related health problems of international statistical classification of ICD-10” to analyze 101 copies of medical records from July 1 ,2011 to June 31 ,2012 diagnosed of upper gastrointestinal bleeding of the tertiary general hospital from the choice of the leading words to diagnosis coding .Results Coding of K92 .2 of 101 copies of medical records ,92 underwent endoscopy ,w hich accounted for 91 .09% of al cases diagnosed of upper gastrointesti-nal bleeding by doctors .We read the 92 copies of medical records underwent endoscopy again and found 23 cases of gastric ulcer bleeding and gastric mucosal lesions bleeding ,accounting for 25% ;2 cases of duodenal ulcer bleeding ,accounting for 2 .17% ;67 cases of esophageal variceal bleeding and esophageal mucosal laceration ,accounting for 72 .83% .Conclusion Coders should not only master the coding knowledge ,but also read medical records careful y ,learn related medical knowledge and code accurately in their daily work to serve medical treatment ,teach and research better .