医学信息
醫學信息
의학신식
MEDICAL INFORMATION
2014年
38期
453-454
,共2页
梗阻性分娩%产科诊断%ICD-10编码%主导词%病例分析%产科学
梗阻性分娩%產科診斷%ICD-10編碼%主導詞%病例分析%產科學
경조성분면%산과진단%ICD-10편마%주도사%병례분석%산과학
Obstructed labor%Obstetric diagnosis%ICD-10 coding%Leading word%Case analysis%Obstetrics
通过临床实例分析探讨产科疾病分类的特殊性并对错误原因进行分析。产科疾病诊断编码强调时效性，以梗阻性分娩为例，阐述相同的症状发生在不同时期对编码的影响。编码人员在编码中应认真阅读待产观察单及病程等相关资料，只看病案首页，不看病案内容，或过度依赖计算机，不按编码规则查找等都会造成编码错误。编码人员对产科疾病进行分类时应仔细阅读病案，严格按照编码规则查找编码，加强对产科相关知识的学习，才能提高编码准确率。
通過臨床實例分析探討產科疾病分類的特殊性併對錯誤原因進行分析。產科疾病診斷編碼彊調時效性，以梗阻性分娩為例，闡述相同的癥狀髮生在不同時期對編碼的影響。編碼人員在編碼中應認真閱讀待產觀察單及病程等相關資料，隻看病案首頁，不看病案內容，或過度依賴計算機，不按編碼規則查找等都會造成編碼錯誤。編碼人員對產科疾病進行分類時應仔細閱讀病案，嚴格按照編碼規則查找編碼，加彊對產科相關知識的學習，纔能提高編碼準確率。
통과림상실례분석탐토산과질병분류적특수성병대착오원인진행분석。산과질병진단편마강조시효성，이경조성분면위례，천술상동적증상발생재불동시기대편마적영향。편마인원재편마중응인진열독대산관찰단급병정등상관자료，지간병안수혈，불간병안내용，혹과도의뢰계산궤，불안편마규칙사조등도회조성편마착오。편마인원대산과질병진행분류시응자세열독병안，엄격안조편마규칙사조편마，가강대산과상관지식적학습，재능제고편마준학솔。
Explore the specificity about ICD-10 coding of obstetric diseases and analyze the cause of er or coding's based on analysis of clinical case.Obstetric diagnosis coding emphasize timeliness.As example as obstructed labor,the same symptoms occur at dif erent stages of labor are classified with dif erent code.Coders should read the partogramt observation careful y and progress note during coding.Just reading the frontpage of medical record without refer to the progress note,or overdependency on the computer assistant coding system without comply with the disease classification principles wil cause coding er or.In order to improve coding accuracy,coders should read the medical record careful y,seek the code strictly according to the disease classification principles,strengthen learning about obstetric-related knowledge.
